Optimising primary care management of patients following acute coronary syndrome

Amar Rai; Rahul Penumaka; Meenakshi Jhala; Nicholas Jones; Thomas Round

doi:10.3399/BJGP.2025.0403

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Optimising primary care management of patients following acute coronary syndrome; author response to Dr Sharvill and Dr Singh
Thomas Round

Published on: 20 November 2025
Optimising care post acute coronary syndrome
John Sharvill

Published on: 10 November 2025
Optimising post-ACS care: the case for a structured 14-day check
Angad Singh

Published on: 08 November 2025

Published on: (20 November 2025)
Page navigation anchor for Optimising primary care management of patients following acute coronary syndrome; author response to Dr Sharvill and Dr Singh
Optimising primary care management of patients following acute coronary syndrome; author response to Dr Sharvill and Dr Singh
Thomas Round, GP and NIHR Clinical Lecturer, King's College London
We would like to thank both Dr. Sharvill and Dr. Singh, for your valuable comments on our article.¹ In terms of gastro-protection, PPIs are recommended with DAPT,² for monotherapy this depends on individual risk assessment for GI bleeding. For clopidogrel alone lansoprazole is recommended if starting a PPI.

We acknowledge evolving evidence for shorter DAPT or de-escalation for high bleeding risk patients, as shown in our Figure 1. Initial selection and duration are usual secondary care remit, with primary care monitoring adherence and complications.

Thank you for also highlight evolving longer term evidence that for secondary prevention monotherapy clopidogrel is preferential to aspirin.³

For AF patients, DOACs are essential for stroke prevention. The complex decision to combine or discontinue antiplatelets in patients on DOACs is usually specialist-guided, balancing thrombotic and bleeding risks.

Our article also outlines a stepwise lipid management approach, with secondary care referral for inclisiran consideration if oral therapies don't meet targets.

We agree that post-ACS review is crucial, representing "smarter, proactive care" and we hope our article can help GPs and primary care teams to formalise and validate this work, emphasising that proper resourcing and clear guidelines are essential for high-quality care.

Dr Thomas Round, on behalf of co-authors.

Re...
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We would like to thank both Dr. Sharvill and Dr. Singh, for your valuable comments on our article.¹ In terms of gastro-protection, PPIs are recommended with DAPT,² for monotherapy this depends on individual risk assessment for GI bleeding. For clopidogrel alone lansoprazole is recommended if starting a PPI.

We acknowledge evolving evidence for shorter DAPT or de-escalation for high bleeding risk patients, as shown in our Figure 1. Initial selection and duration are usual secondary care remit, with primary care monitoring adherence and complications.

Thank you for also highlight evolving longer term evidence that for secondary prevention monotherapy clopidogrel is preferential to aspirin.³

For AF patients, DOACs are essential for stroke prevention. The complex decision to combine or discontinue antiplatelets in patients on DOACs is usually specialist-guided, balancing thrombotic and bleeding risks.

Our article also outlines a stepwise lipid management approach, with secondary care referral for inclisiran consideration if oral therapies don't meet targets.

We agree that post-ACS review is crucial, representing "smarter, proactive care" and we hope our article can help GPs and primary care teams to formalise and validate this work, emphasising that proper resourcing and clear guidelines are essential for high-quality care.

Dr Thomas Round, on behalf of co-authors.

References

1. Rai A, Penumaka R, Jhala M, Jones N, Round T. Optimising primary care management of patients following acute coronary syndrome. Br J Gen Pract 2025; 75(760):531-4.
2. Byrne RA, Rossello X, Coughlan JJ et al. 2023 ESC Guidelines for the management of acute coronary syndromes: Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology (ESC). Eur. Heart J 2023; 44(38): 3720–3826.
3. Valgimigli M, Choi KH, Giacoppo D et al. Clopidogrel versus aspirin for secondary prevention of coronary artery disease: a systematic review and individual patient data meta-analysis. The Lancet 2025; 406(10508):1091-102.
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Competing Interests: BJGP Associate Editor.
Published on: (10 November 2025)
Page navigation anchor for Optimising care post acute coronary syndrome
Optimising care post acute coronary syndrome
John Sharvill, GP nearly retired, None
May I ask the authors views on gastro protection. Is it needed for dual or single anti-platelet agents?

Many recent articles seem to be suggesting 1 year is not needed for dual therapy and may cause more harm than benefit compared to shorter courses (recognising there are exceptions), and that clopidogrel may be better than aspirin as long term single agent. There is also only a brief mention for those with AF, but when should antiplatelet agents be stopped in favour of long-term use of apixaban or equivalent?

Regarding cholesterol and lipids. The UK NHS was very keen for GPs to initiate incliseran a few years ago, possibly for commercial reasons. Here, we are advised to refer to secondary care if targets are not met. Where are we on incliseran evidence and use?

May I also comment on Dr A Singh's response that GP review should be incentivised of review these patients. My view is that it is a basic core part of being a GP, and the danger is that many things are being rejected by primary care unless spelt out or separately paid for in addition to basic funding.

Competing Interests: None declared.
Published on: (8 November 2025)
Page navigation anchor for Optimising post-ACS care: the case for a structured 14-day check
Optimising post-ACS care: the case for a structured 14-day check
Angad Singh, GP Registrar, Cathedral Medical Centre
We read with interest the review by Rai et al. on managing post-ACS patients in primary care. The authors correctly highlighted the critical failure in the current system as evidenced by the high 30-day readmission rate for post-ACS patients. This is correctly attributable to the 'disjointed' transition from hospital to primary care and the 'underutilisation' of key interventions like cardiac rehabilitation.

We suggest a formal, structured, and incentivised primary care review for all post-ACS patients within 14 days of discharge. It is well known that this immediate post-discharge period carries the highest risk of complications, non-adherence, and preventable readmission.

This "post-ACS check", therefore, analogous to the six-week postnatal check, can be the first real-world opportunity to:

Screen for aforementioned red flags and confirm adherence to secondary prevention medications.

Address the well-known psychological concerns related to a significant cardiac event and promote health literacy, including a targeted lipid intervention, side-effect discussions, and support for engagement with cardiac rehabilitation programmes.

This is not about creating added work but about smarter, proactive care. A single, structured review (perhaps added to QOF) would prevent the multiple reactive appointments, A&E attendances, and preventable readmissions that our current passive system guarant...
Show More

We read with interest the review by Rai et al. on managing post-ACS patients in primary care. The authors correctly highlighted the critical failure in the current system as evidenced by the high 30-day readmission rate for post-ACS patients. This is correctly attributable to the 'disjointed' transition from hospital to primary care and the 'underutilisation' of key interventions like cardiac rehabilitation.

We suggest a formal, structured, and incentivised primary care review for all post-ACS patients within 14 days of discharge. It is well known that this immediate post-discharge period carries the highest risk of complications, non-adherence, and preventable readmission.

This "post-ACS check", therefore, analogous to the six-week postnatal check, can be the first real-world opportunity to:

Screen for aforementioned red flags and confirm adherence to secondary prevention medications.

Address the well-known psychological concerns related to a significant cardiac event and promote health literacy, including a targeted lipid intervention, side-effect discussions, and support for engagement with cardiac rehabilitation programmes.

This is not about creating added work but about smarter, proactive care. A single, structured review (perhaps added to QOF) would prevent the multiple reactive appointments, A&E attendances, and preventable readmissions that our current passive system guarantees.

Show Less
Competing Interests: None declared.

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