Table 1.

Summary of pharmacotherapy post-acute coronary syndrome and considerations in the older population.

Drug Class † and Mechanism of Action	Side Effects	Drug–Disease Interactions (Side Effects)	Drug–Drug Interactions (Side Effects)	Other Considerations in the Older Population	Duration of Use
Antiplatelet therapy Aspirin Irreversibly binds to cyclo-oxygenase, reducing the synthesis of thromboxane A2 (inducer of platelet aggregation)	GI ulceration, bleeding, skin reactions	Gastritis or peptic ulcer disease, bleeding disorders, severe hepatic disease (↑ bleeding risk), asthma (bronchospasm)	Corticosteroids, NSAIDs (↑risk of gastric ulceration) Anticoagulants (↑ bleeding)	Continued assessment of bleeding risk through risk stratification, reviewing concurrent comorbidities and medications	Long-term *
P2Y12 inhibitor therapy Prasugrel, Clopidogrel, Ticagrelor Binds irreversibly (prasugrel, clopidogrel) or reversibly (ticagrelor) to the P2Y12 receptor inhibiting platelet aggregation	GI ulceration, bleeding Ticagrelor—dyspnea, non-cardiac chest pain, raised uric acid concentration	Bleeding disorders, severe hepatic disease (↑ bleeding risk) Prasugrel—previous stroke or TIA (↑ bleeding risk and risk of hemorrhagic strokes)	Clopidogrel CYP2C19 heterogenicity—poor metabolizers (↓ efficacy), PPIs—omeprazole, esomeprazole (↓ efficacy) Ticagrelor—CYP3A4 inhibitors (↑ bleeding)	Continued assessment of bleeding risk through risk stratification, reviewing concurrent comorbidities and medications	Figure 3
Lipid-lowering therapy Atorvastatin, Rosuvastatin (high-intensity) HMG-CoA reductase inhibitors (statins) increases hepatic cholesterol uptake from the blood. Atherosclerotic lesion/plaque stabilization	Myalgia and myopathy, sleep disturbance (insomnia, nightmares), liver toxicity	Chronic liver disease diabetes, CKD, (statin -induced myopathy)	Atorvastatin—dose reduction with CYP3A4 inhibitors	Close monitoring of side effects as myopathies may impact on physical function, frailty and falls and sleep disturbances may impact on risk of delirium and falls	Long-term *
Beta-blocker therapy Reduces heart rate and blood pressure, modulates myocardial contractility and oxygen demand, can improve myocardial ischemia and reduce ventricular arrythmias	Bradycardia, hypotension, fatigue, bronchospasm, claudication, masking symptoms of hypoglycemia and depression	COPD or asthma (bronchospasm), diabetes (hypoglycemia), renal impairment, AV node dysfunction (bradycardia), PVD (claudication)	Gliclazides (hypoglycemia), AV nodal blocking medications (bradycardia)	Close monitoring of side effects as hypotension and bradycardia may increase falls risk, fatigue may decrease function and independence	Consider cessation at 3 years or sooner
ACEI and ARBs Inhibition of the angiotensin converting enzyme or angiotensin receptor blocker	Hypotension, hyperkalemia, worsening renal function, angioedema, cough (ACEI)	CKD (hyperkalemia and renal failure)	Trimethoprim, ciclosporin (increase potassium concentration) NSAIDs, diuretics (impaired renal function)	Close monitoring of side effects as hypotension can increase falls risk	Long-term *

* Long-term: Defined as a time course in which medications that are life-prolonging are continued in alignment with the patient’s current values, preferences, and overall prognosis. If these values and preferences change or overall prognosis becomes poor, these medications should be reviewed and deprescribed as appropriate. In addition, if any harm or adverse effects occur then they should be discontinued. † Bold text identifies the drug classes and examples of drugs within the drug classes where relevant. ↓: refers to decreased, ↑: refers to increased, ACEI: angiotensin-converting enzyme inhibitor; ARBs: angiotensin receptor blocker; AV: atrioventricular; CCB: calcium channel blockers; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; eg: for example; GI: gastrointestinal; HFrEF: heart failure with reduced ejection fraction defined as left ventricular ejection fraction ≤ 40%; HMG-CoA: 3-Hydroxy-3-methylglutaryl coenzyme A; NSAIDs: non-steroidal anti-inflammatories; PPI: proton pump inhibitor, PVD: peripheral vascular disease; TIA: transient ischemic attack.