2025 ACC/AHA/ Guideline for the Management of Patients With Acute Coronary Syndromes

Introduction:

This summary highlights the key points from the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Clinical Practice Guideline on the management of acute coronary syndromes (ACS). It covers both ST-segment elevation myocardial infarction (STEMI) and non–ST-segment elevation ACS (NSTE-ACS), emphasizing timely diagnosis, reperfusion strategies, risk stratification, and secondary prevention. The primary aim is to help clinicians provide evidence-based and up-to-date care to reduce mortality, complications, and long-term adverse outcomes in patients with ACS.

Key Recommendations:

• Early and Accurate Diagnosis

  • Obtain and interpret a 12-lead ECG within 10 minutes of first medical contact in suspected ACS.
  • Use high-sensitivity troponin testing to accelerate ruling in/out myocardial infarction.

• Reperfusion in STEMI

  • Primary percutaneous coronary intervention (PPCI) is the preferred strategy if it can be performed within 90 minutes (or 120 minutes for transfers).
  • In patients with anticipated long delays, fibrinolytic therapy is recommended if there are no contraindications and the patient presents within 12 hours of symptom onset.

• Routine Invasive vs. Selective Invasive Strategy in NSTE-ACS

  • Patients at intermediate or high ischemic risk benefit from an invasive strategy during hospitalization.
  • Low-risk patients may undergo a selective invasive approach, incorporating noninvasive testing to guide the need for angiography.

• Multivessel Coronary Artery Disease Management

  • For hemodynamically stable STEMI patients with nonculprit lesions, complete revascularization (either during the index procedure or staged) lowers future events.
  • In NSTE-ACS, complete revascularization decisions (PCI vs. CABG) depend on anatomical complexity and comorbidities.

• Antithrombotic Therapy

  • Initiate dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor (ticagrelor or prasugrel preferred over clopidogrel for most) for at least 12 months in patients without high bleeding risk.
  • To reduce bleeding risk in patients with ACS several strategies are available:
    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;
    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).

• Parenteral Anticoagulation

  • All ACS patients should receive an anticoagulant (e.g., unfractionated heparin, low-molecular-weight heparin, bivalirudin) depending on the clinical scenario and planned strategy (PCI, CABG, or medical management).

• Lipid Management

  • High-intensity statin therapy is recommended in all ACS patients.
  • Add a nonstatin agent (e.g., ezetimibe, PCSK9 inhibitor) if LDL cholesterol remains ≥70 mg/dL on maximally tolerated statin.

• Heart Failure and Cardiogenic Shock

  • In acute MI with cardiogenic shock, immediate revascularization of the culprit lesion is indicated.
  • Selected patients with STEMI-related cardiogenic shock may benefit from a short-term microaxial flow pump if they fit specific criteria; close attention to vascular complications and renal failure is required.

• In-Hospital Care and Complications

  • Use telemetry for rhythm monitoring in unstable patients and evaluate left ventricular ejection fraction prior to discharge.
  • Mechanical complications (e.g., ventricular septal rupture) require rapid surgical consultation; short-term mechanical circulatory support devices may be a bridge to surgery.

• Secondary Prevention and Discharge

  • Refer all patients to a cardiac rehabilitation program to reduce rehospitalizations and improve functional status. A home-based program is acceptable when center-based options are not feasible.
  • Repeat lipid panel 4 to 8 weeks postdischarge to confirm adequate LDL-lowering.
  • Annual influenza vaccination is recommended to reduce cardiovascular events and mortality.
  • Consider low-dose colchicine in certain post-ACS patients to reduce the risk of recurrent ischemic events if there are no contraindications.
  • Based on one trial, red blood cell transfusion to maintain hemoglobin of 10 g/dL may be reasonable in patients with ACS and acute or chronic anemia who are not actively bleeding.

Conclusion:
Adherence to these recommendations can significantly improve in-hospital and postdischarge outcomes for patients with acute coronary syndromes. By focusing on rapid identification, prompt reperfusion, tailored antithrombotic therapies, aggressive risk factor modification, and ongoing follow-up (including cardiac rehabilitation), clinicians can lower morbidity, mortality, and readmissions. The guideline also underscores the need to balance bleeding and ischemic risks, use high-intensity lipid-lowering strategies, and provide a structured discharge plan for long-term secondary prevention.

Reference:
Rao SV, O’Donoghue ML, Ruel M, et al. 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. Journal of the American College of Cardiology. In Press, Corrected Proof. Available online 27 February 2025. DOI: https://doi.org/10.1016/j.jacc.2024.11.009