Top Things to Know: 2025 Guideline for Acute Coronary Syndromes
Published: February 27, 2025
- Dual antiplatelet therapy is recommended in ACS patients. Ticagrelor or prasugrel is recommended in preference to clopidogrel in NSTE-ACS and STEMI patients undergoing PCI. In patients with NSTE-ACS planned for an invasive strategy with timing of angiography to be >24 hours, upstream treatment with clopidogrel or ticagrelor may be considered to reduce MACE.
- 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: a) in patients at risk for gastrointestinal bleeding, a proton pump inhibitor is recommended; b) in patients who have tolerated DAPT with ticagrelor, transition to ticagrelor monotherapy is recommended ≥ 1 month post PCI; c) in patients who require long-term anticoagulation, aspirin discontinuation is recommended 1-4 weeks after PCI with continued use of a P2Y12 inhibitor (preferably clopidogrel).
- High-intensity statin therapy is recommended for all ACS patients with the option to initiate concurrent ezetimibe. A non-statin lipid lowering agent (ezetimibe, evolocumab, alirocumab, inclisiran, bempedoic acid) is recommended for patients already on maximally tolerated statin who have an LDL-C ≥70 mg/dl (1.8 mmol/L). It is reasonable in this high-risk population to further intensify lipid-lowering therapy if LDL-C 55-<70mg/dl (1.4-<1.8 mmol/L) and already on maximally tolerated statin.
- In patients with NSTE-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 MACE. In patients with NSTE-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 MACE.
- Two procedural strategies are recommended in ACS patients undergoing PCI: a) a radial approach is preferred over femoral approach in patients with ACS undergoing PCI to reduce bleeding, vascular complications, and mortality; b) Intravascular imaging is recommended to guide PCI in patients with ACS with complex coronary lesions.
- A strategy of complete revascularization is recommended in both STEMI and NSTE-ACS patients. The choice of revascularization method (ie CABG vs multivessel PCI) in NSTE-ACS and multivessel disease should be based on the complexity of their coronary artery disease and their comorbid conditions. PCI of significant non-culprit stenoses for patients with STEMI 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 non-infarct-related arteries at the time of PCI is not recommended.
- Based on one trial, use of the microaxial flow pump in selected patients with AMI-CS is reasonable to reduce mortality. 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.
- 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.
- After discharge, focus on secondary prevention is fundamental: a fasting lipid panel is recommended 4 to 8 weeks after initiation or dose adjustment of lipid-lowering therapy and referral to cardiac rehabilitation is recommended, with the option for home-based programs for patients who are otherwise not able or willing to attend in-person.
Citation
Rao SV, O’Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, Morrow DA, Baber U, Mukherjee D, Baker H, Platz E, Cohen MG, MD, Promes SB, Cruz-Ruiz M, Sandner S, Davis LL, Sandoval Y, de Lemos JA, Schunder R, DeWald TA, Binita Shah B, Elgendy IY, Stopyra JP, Feldman DN, Talbot AW, Goyal A, Taub PR, Isiadinso I, Williams MS, Menon V. 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. Circulation. Published online February 27, 2025. doi: 10.1161/CIR.0000000000001309