No changes should be made to this patient's medications at the time of hospital discharge.
Calcium channel blockers, with the exception of nifedipine, can be used in patients with contraindications to β-blockers and in those with continued angina despite optimal doses of β-blockers and nitrates. This patient has no indications for a calcium channel blocker such as diltiazem.
There is no evidence to support a change from ticagrelor to clopidogrel after percutaneous coronary intervention (PCI) for acute coronary syndrome. In the PLATO (PLATelet inhibition and patient Outcomes) trial, the use of ticagrelor was associated with a 1.9% absolute risk reduction in the occurrence of cardiovascular death, myocardial infarction, and stroke when compared with clopidogrel. A P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) should be continued for at least 1 year for patients undergoing PCI with stent placement.
Oral β-blockers should be given to all patients with acute coronary syndrome without a contraindication (decompensated heart failure, advanced atrioventricular block, or severe reactive airways disease) and continued indefinitely. This patient is already bradycardic, and an increase in the dosage of metoprolol may be associated with symptomatic bradycardia.
In this patient with an acute coronary syndrome and preserved left ventricular function, there is no evidence to support the use of an aldosterone antagonist such as eplerenone. Based on the EPHESUS (Eplerenone Post-AMI Heart Failure Efficacy and Survival) trial, the 2007 American College of Cardiology/American Heart Association guidelines recommend the administration of an aldosterone antagonist to all patients following a non–ST-elevation myocardial infarction (NSTEMI) who are receiving an ACE inhibitor, have a left ventricular ejection fraction of 40% or below, and have either heart failure symptoms or diabetes mellitus.
ACE inhibitors inhibit postinfarction remodeling, helping to preserve ventricular function. ACE inhibitors should be continued indefinitely.