ACC/AHA Release 2025 Guidelines for Acute Coronary Syndrome: What's New in Patient Care?

This comprehensive update, published in the Journal of the American College of Cardiology (JACC), is the first unified revision in over a decade and integrates new evidence since the previous STEMI and NSTE-ACS guidelines to improve patient care and outcomes.

Key Recommendations:

1. Dual Antiplatelet Therapy (DAPT): For patients with ACS undergoing percutaneous coronary intervention (PCI), the committee recommends
   DAPT. Ticagrelor or prasugrel is preferred over clopidogrel. In NSTE-ACS patients scheduled for angiography beyond 24 hours, early treatment with clopidogrel or ticagrelor may reduce major adverse cardiovascular events.
2. Duration and Modification of DAPT: A minimum of 12 months of DAPT is advised for ACS patients without high bleeding risk. To mitigate bleeding in PCI-treated patients:
   • Proton pump inhibitors are recommended for those at gastrointestinal bleeding risk.
   • Transitioning to ticagrelor monotherapy is advised after one month of DAPT.
   • For patients on long-term anticoagulation, discontinuing aspirin 1-4 weeks post-PCI while continuing a P2Y12 inhibitor (preferably clopidogrel) is recommended.
3. Lipid Management: High-intensity statin therapy is recommended for all ACS patients, with the option to initiate concurrent ezetimibe. For those on maximally tolerated statins with LDL cholesterol levels ≥70 mg/dL (1.8 mmol/L), adding nonstatin agents (e.g., ezetimibe, evolocumab, alirocumab, inclisiran, bempedoic acid) is advised. Intensifying lipid-lowering therapy is reasonable for patients with LDL levels between 55 and 70 mg/dL.
4. Invasive Strategies for NSTE-ACS: An invasive approach during hospitalization is recommended for NSTE-ACS patients at intermediate or high ischemic risk to reduce major adverse cardiovascular events. For low-risk patients, a routine or selective invasive approach with further risk stratification is advised.
5. PCI Procedural Strategies: The radial approach is preferred over the femoral approach in ACS patients undergoing PCI to reduce bleeding, vascular complications, and mortality. Additionally, intracoronary imaging is recommended to guide PCI in patients with complex coronary lesions.
6. Complete Revascularization: A strategy of complete revascularization is recommended for patients with STEMI or NSTE-ACS. The choice between coronary artery bypass graft surgery and multivessel PCI should be based on coronary disease complexity and comorbid conditions. In STEMI patients, PCI of significant nonculprit lesions can be performed during the initial procedure or staged, with a preference for a single procedure. In ACS patients with cardiogenic shock, emergency revascularization of the culprit vessel is indicated; routine PCI of noninfarct-related arteries at the time of PCI is not recommended.
7. Mechanical Support in Cardiogenic Shock: The use of a microaxial flow pump in selected patients with cardiogenic shock due to acute myocardial infarction is reasonable to reduce mortality. However, increased complications such as bleeding, limb ischemia, and renal failure necessitate careful attention to vascular access and timely weaning of support to balance benefits and risks.
8. Red Blood Cell Transfusion:
   Maintaining a hemoglobin level of 10 g/dL through red blood cell transfusion may be reasonable in ACS patients with acute or chronic anemia who are not actively bleeding.
9. Secondary Prevention Post-Discharge: Emphasis on secondary prevention is crucial. A fasting lipid panel is recommended 4 to 8 weeks after initiating or adjusting lipid-lowering therapy. Referral to cardiac rehabilitation is advised, with home-based programs as alternatives for patients unable or unwilling to attend in person.

"These updated guidelines emphasize the importance of individualized treatment strategies and the integration of new evidence to optimize care for patients with acute coronary syndromes," the committee led by Sunil V. Rao, Department of Cardiovascular Medicine, NYU Grossman School of Medicine, New York, New York, USA, concluded.

Reference:

Rao SV, O’Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, Baber U, Baker H, Cohen MG, Cruz-Ruiz M, Davis LL, de Lemos JA, DeWald TA, Elgendy IY, Feldman DN, Goyal A, Isiadinso I, Menon V, Morrow DA, Mukherjee D, Platz E, Promes SB, Sandner S, Sandoval Y, Schunder R, Shah B, Stopyra JP, Talbot AW, Taub PR, Williams MS. 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. JACC. Published online February 27, 2025. https://doi.org/10.1016/j.jacc.2024.11.009