Which medications started in the ED after ACS have mortality benefits and are standard of care?

• A. Nitrates for pain only
• B. Antibiotics and diuretics
• C. Calcium channel blockers only
• D. Aspirin, beta-blocker, ACE inhibitor or ARB, statin; add a P2Y12 inhibitor if PCI planned; nitrates for pain as needed

Answer: (D)

In ACS care started in the ED, therapies that have been shown to improve survival and long-term outcomes are given early. Aspirin immediately inhibits platelet aggregation, reducing thrombus growth and recurrent events, which translates to a mortality benefit. A beta-blocker started promptly lowers heart rate and myocardial oxygen demand, helping limit infarct size and reduce the risk of death when not contraindicated. An ACE inhibitor or ARB is started to prevent adverse remodeling of the LV and improve survival, especially in patients with reduced systolic function, hypertension, or heart failure risk. A high-intensity statin is begun to stabilize plaques, reduce inflammation, and lower recurrent cardiovascular events, contributing to better survival. If PCI is planned, adding a P2Y12 inhibitor (such as clopidogrel, ticagrelor, or prasugrel) is essential to prevent stent thrombosis and improve outcomes after the procedure. Nitrates provide pain relief and symptomatic improvement, but they have no proven mortality benefit when used for ACS beyond relief of ischemia. Putting these together—the antiplatelet/antithrombotic strategy, beta-blocker, ACE inhibitor or ARB, statin, and, if PCI is planned, a P2Y12 inhibitor—reflects the standard of care with mortality benefits started in the ED.