Today, I review, link to, and excerpt from 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Circulation. 2025 Apr;151(13):e771-e862. doi: 10.1161/CIR.0000000000001309. Epub 2025 Feb 27.
The above article has been cited by 273 articles in PubMed.
All that follows is from the above resource.
Abstract
Aim: The “2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes” incorporates new evidence since the “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction” and the corresponding “2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes” and the “2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction.” The “2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes” and the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” retire and replace, respectively, the “2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease.”
Methods: A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.
Structure: Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
Keywords: AHA Scientific Statements; EMS; ST-segment elevation myocardial infarction; acute coronary syndrome(s); angina, unstable; anticoagulants; aspirin; atrial fibrillation; cardiovascular diseases; coronary artery disease; coronary syndrome; emergency medical services; fibrinolytic agents; hemorrhage; major adverse cardiovascular events; morphine; myocardial infarction; non–ST-segment elevation myocardial infarction; percutaneous coronary intervention; prehospital; revascularization; risk; time factors; treatment outcome.
Top Take-Home Messages
1.Dual antiplatelet therapy is recommended for patients with acute coronary syndromes (ACS). Ticagrelor or prasugrel is recommended in preference to clopidogrel in patients with ACS who are undergoing percutaneous coronary intervention (PCI). In patients with non–ST-segment elevation ACS who are scheduled for an invasive strategy with timing of angiography to be >24 hours, upstream treatment with clopidogrel or ticagrelor may be considered to reduce major adverse cardiovascular events.2.Dual antiplatelet therapy with aspirin and an oral P2Y12 inhibitor is indicated for at least 12 months as the default strategy in patients with ACS who are not at high bleeding risk. Several strategies are available to reduce bleeding risk in patients with ACS who have undergone PCI and require antiplatelet therapy: (a) in patients at risk for gastrointestinal bleeding, a proton pump inhibitor is recommended; (b) in patients who have tolerated dual antiplatelet therapy with ticagrelor, transition to ticagrelor monotherapy is recommended ≥1 month after PCI; or (c) in patients who require long-term anticoagulation, aspirin discontinuation is recommended 1 to 4 weeks after PCI with continued use of a P2Y12 inhibitor (preferably clopidogrel).3.High-intensity statin therapy is recommended for all patients with ACS, and with the option to initiate concurrent ezetimibe. A nonstatin lipid-lowering agent (eg, ezetimibe, evolocumab, alirocumab, inclisiran, bempedoic acid) is recommended for patients already on maximally tolerated statin who have a low-density lipoprotein cholesterol level of ≥70 mg/dL (1.8 mmol/L). It is reasonable in this high-risk population to further intensify lipid-lowering therapy if the low-density lipoprotein cholesterol level is 55 to <70 mg/dL (1.4 to <1.8 mmol/L) and patient is already on a maximally tolerated statin.4.In patients with non–ST-segment elevation ACS who are at intermediate or high risk of ischemic events, an invasive approach with the intent to proceed with revascularization is recommended during hospitalization to reduce major adverse cardiovascular events. In patients with non–ST-segment elevation ACS who are at low risk of ischemic events, a routine invasive or selective invasive approach with further risk stratification is recommended to help identify those who may require revascularization and to reduce major adverse cardiovascular events.5.Two procedural strategies are recommended in patients with ACS who are undergoing PCI: (a) radial approach is preferred over femoral approach in patients with ACS undergoing PCI to reduce bleeding, vascular complications, and death; and (b) intracoronary imaging is recommended to guide PCI in patients with ACS with complex coronary lesions.6.A strategy of complete revascularization is recommended in patients with ST-segment elevation myocardial infarction or non–ST-segment elevation ACS. The choice of revascularization method (ie, coronary artery bypass graft surgery versus multivessel PCI) in non–ST-segment elevation ACS and multivessel disease should be based on the complexity of the coronary artery disease and comorbid conditions. PCI of significant nonculprit stenoses for patients with ST-segment elevation myocardial infarction can be performed in a single procedure or staged with some preference toward performing multivessel PCI in a single procedure. In patients with ACS and cardiogenic shock, emergency revascularization of the culprit vessel is indicated; however, routine PCI of noninfarct-related arteries at the time of PCI is not recommended.7.Based on one trial, use of the microaxial flow pump in selected patients with cardiogenic shock related to acute myocardial infarction is reasonable to reduce death. However, complications such as bleeding, limb ischemia, and renal failure are higher with the microaxial flow pump compared with usual care. Therefore, careful attention to vascular access and weaning of support is important to appropriately balance the benefits and risks.8.Red blood cell transfusion to maintain a hemoglobin of 10 g/dL may be reasonable in patients with ACS and acute or chronic anemia who are not actively bleeding.9.After discharge, focus on secondary prevention is fundamental. A fasting lipid panel is recommended 4 to 8 weeks after initiating or adjusting the dose of lipid-lowering therapy. Referral to cardiac rehabilitation is also recommended, with the option for home-based programs for patients unable or unwilling to attend in person.Table of Contents
Abstract 2136Top Take-Home Messages 2138Preamble 21391.Introduction 21401.1.Methodology and Evidence Review 21401.2.Composition of the Writing Committee 21411.3.Guideline Review and Approval 21411.4.Scope of the Guideline 21411.5.Class of Recommendation and Level of Evidence 21421.6.Abbreviations 21442.Overview of ACS 21442.1.Definition and Classification of ACS 21443.Initial Evaluation and Management of Suspected ACS 21473.1.Initial Assessment of Suspected ACS 21473.1.1.Prehospital Assessment and Management Considerations for Suspected ACS 21473.1.2.Initial In-Hospital Assessment of Patients With Confirmed or Suspected ACS 21493.1.3.Risk Stratification Tools for Patients With STEMI and NSTE-ACS 21513.2.Management of Patients Presenting With Cardiac Arrest 21524.Standard Medical Therapies for STEMI and NSTE-ACS 21534.1.Oxygen Therapy 21534.2.Analgesics 21544.3.Antiplatelet Therapy 21554.3.1.Aspirin 21554.3.2.Oral P2Y12 Inhibitors During Hospitalization 21564.3.3.Intravenous P2Y12 Inhibition 21594.3.4.Intravenous Glycoprotein IIb/IIIa Inhibitors 21604.4.Parenteral Anticoagulation 21614.5.Lipid Management 21654.6.Beta-Blocker Therapy 21684.7.Renin-Angiotensin-Aldosterone System Inhibitors 21695.STEMI Management: Reperfusion Strategies 21705.1.Regional Systems of STEMI Care 21705.2.Reperfusion at PCI-Capable Hospitals 21725.2.1.PPCI in STEMI 21725.2.2.Urgent CABG Surgery 21735.3.Reperfusion at Non–PCI-Capable Hospitals 21745.3.1.Timing and Choice of Agent for Fibrinolytic Therapy 21755.3.2.Coronary Angiography and PCI After Fibrinolytic Therapy 21766.NSTE-ACS: Routine Invasive or Selective Invasive Initial Approach 21776.1.Rationale and Timing for a Routine Invasive or Selective Invasive Approach 21777.Catheterization Laboratory Considerations in ACS 21807.1.Vascular Access Approach for PCI 21807.2.Use of Aspiration Thrombectomy 21817.3.Use of Intracoronary Imaging 21827.4.Management of Multivessel CAD in ACS 21837.4.1.Management of Multivessel CAD in STEMI 21837.4.2.Management of Multivessel CAD in NSTE-ACS 21858.Cardiogenic Shock Management 21868.1.Revascularization in ACS With Cardiogenic Shock 21868.2.MCS in Patients With ACS and Cardiogenic Shock 21879.ACS Complications 21899.1.Mechanical Complications 21899.2.Electrical Complications and Prevention of Sudden Cardiac Death After ACS 21909.3.Pericarditis Management After MI 21929.4.Management of LV Thrombus After MI 219210.In-hospital Issues in the Management of ACS 219310.1.Cardiac Intensive Care Unit 219310.2.Management of Anemia in ACS 219310.3.Telemetry and Length of Stay 219410.4.Noninvasive Diagnostic Testing Prior to Hospital Discharge 219510.5.Discharge Planning 219510.5.1.Patient Education 219510.5.2.Postdischarge Follow-Up and Systems of Care Coordination 219610.5.3.Cardiac Rehabilitation 219711.Discharge: Long-Term Management and Secondary Prevention 219811.1.DAPT Strategies in the First 12 Months Postdischarge 219811.1.1.Antiplatelet Therapy in Patients on Anticoagulation Postdischarge 220111.2.Reassessment of Lipid Levels Postdischarge 220211.3.SGLT-2 Inhibitors and GLP-1 Receptor Agonists 220311.4.Use of Chronic Colchicine 220311.5.Immunization 220412.Evidence Gaps and Future Directions 2204References 2207Appendix 1Author Relationships With Industry and Other Entities 2230Appendix 2Reviewer Relationships With Industry and Other Entities 2236
