2025 ACC/AHA/ACEP/NAEMSP/SCAI
Guideline for the Management of
Patients With Acute Coronary
Syndromes : A Concise Summary
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Definition and Classification of ACS
• ACS results from atherosclerotic plaque rupture, thrombosis, and myocardial
ischemia.
• Three main types:
o STEMI: Complete coronary occlusion with ST elevation on ECG, requiring
urgent reperfusion.
o NSTEMI: Partial occlusion with elevated troponins but no ST elevation.
o UA: Symptoms of ischemia without troponin elevation, indicating possible
plaque instability.
Initial Evaluation and Management of Suspected ACS
• 12-lead ECG within 10 minutes of first medical contact (FMC) to detect STEMI.
• Serial ECGs if the initial ECG is nondiagnostic, especially if symptoms persist or
worsen.
• Risk stratification with clinical history, ECG findings, and cardiac biomarkers.
• Immediate medical therapy: Aspirin, P2Y12 inhibitors, and anticoagulation for all
suspected ACS patients.
• Early invasive strategy for high-risk NSTE-ACS patients.
Initial In-Hospital Assessment of Patients With Confirmed or Suspected ACS
• Cardiac troponin measurement on arrival, preferably high-sensitivity troponin (hs-
cTn).
• Repeat troponin testing at 1-2 hours (hs-cTn) or 3-6 hours (standard cTn) for
dynamic changes.
• Haemodynamic assessment to identify shock or heart failure requiring urgent
intervention.
• Immediate risk stratification using scores like GRACE or TIMI.
Risk Stratification Tools for Patients With STEMI and NSTE-ACS
• STEMI: Requires immediate revascularisation (PCI preferred, fibrinolysis if PCI is
unavailable within 120 min).
• NSTE-ACS: GRACE and TIMI scores help guide the decision for early invasive vs.
conservative management.
• High-risk features include recurrent chest pain, dynamic ECG changes,
haemodynamic instability, or elevated GRACE score.
Management of Patients Presenting With Cardiac Arrest
• Immediate CPR and defibrillation for shockable rhythms.
• Targeted temperature management for post-resuscitation care.
• Urgent coronary angiography for suspected ACS as the cause of arrest.
Standard Medical Therapies for STEMI and NSTE-ACS
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• Oxygen Therapy
o Recommended only if SpO2 <90%.
• Analgesics
o Morphine can be used for pain relief but may slow antiplatelet drug
absorption.
• Antiplatelet Therapy
o Aspirin: Loading dose (162-325 mg), then low-dose (75-100 mg daily).
o P2Y12 inhibitors: Ticagrelor or prasugrel preferred over clopidogrel in PCI
patients.
o Intravenous glycoprotein IIb/IIIa inhibitors: Used selectively in high-risk
PCI cases.
• Parenteral Anticoagulation
o UFH, enoxaparin, or bivalirudin based on bleeding risk and renal function.
• Lipid Management
o High-intensity statin therapy for all ACS patients.
o Ezetimibe or PCSK9 inhibitors for LDL-C >70 mg/dL despite maximal statin
therapy.
• Beta-Blockers
o Initiate within 24 hours unless contraindicated (e.g., cardiogenic shock).
• RAAS Inhibitors (ACEi/ARBs)
o Indicated for LVEF ≤40%, hypertension, diabetes, or CKD.
STEMI Management: Reperfusion Strategies
• PCI-capable hospitals
o Primary PCI (PPCI) is the preferred treatment, with door-to-balloon time ≤90
minutes.
• Non-PCI-capable hospitals
o If PCI cannot be performed within 120 minutes, administer fibrinolytics
within 30 minutes.
o Transfer for rescue PCI if fibrinolysis fails.
• Urgent CABG surgery
o Required for PCI failure or complex CAD with ongoing ischaemia.
NSTE-ACS: Routine Invasive or Selective Invasive Initial Approach
• Routine invasive strategy for high-risk patients (e.g., GRACE score >140, recurrent
symptoms, ECG changes).
• Selective invasive strategy for lower-risk patients after initial medical therapy.
Catheterization Laboratory Considerations in ACS
• Radial access preferred over femoral to reduce bleeding risk.
• Aspiration thrombectomy is not routinely recommended.
• Intracoronary imaging (IVUS/OCT) for optimising PCI in complex lesions.
Management of Multivessel CAD in ACS
• STEMI patients: Complete revascularisation preferred, either staged or during the
index procedure.
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• NSTE-ACS patients: Revascularisation approach depends on clinical and anatomical
factors.
Cardiogenic Shock Management
• Emergency PCI for culprit lesion to restore perfusion.
• Mechanical circulatory support (Impella or VA-ECMO) for selected patients.
ACS Complications
• Mechanical complications: Urgent surgery for ventricular septal defect, papillary
muscle rupture, or free wall rupture.
• Electrical complications: ICD implantation for patients with LVEF ≤35% post-MI.
• Pericarditis: Treated with NSAIDs and colchicine.
• LV thrombus: Anticoagulation recommended.
In-Hospital Issues in ACS Management
• Cardiac Intensive Care Unit (CICU) monitoring for high-risk patients.
• Management of anaemia: RBC transfusion if Hb <8 g/dL.
• Telemetry: Based on risk stratification.
• Pre-discharge noninvasive testing: For patients without prior angiography.
Discharge Planning
• Patient education on medication adherence, lifestyle changes, and symptom
recognition.
• Follow-up within one week to optimise therapy and monitor adherence.
• Cardiac rehabilitation is recommended for all eligible patients.
Long-Term Management and Secondary Prevention
• DAPT for at least 12 months post-ACS, adjusting duration based on bleeding risk.
• Lipid monitoring: Recheck lipid levels 4-8 weeks after initiation or adjustment of
statin therapy.
• SGLT-2 inhibitors and GLP-1 receptor agonists for selected high-risk patients
with diabetes.
• Vaccination: Influenza and pneumococcal vaccines recommended.
Evidence Gaps and Future Directions
• Optimal DAPT duration beyond one year remains under investigation.
• Further studies needed on personalised antithrombotic strategies.
• The role of novel lipid-lowering and anti-inflammatory therapies in long-term ACS
care.
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Reference
1. Rao, S.V., O’Donoghue, M.L., Ruel, M., Rab, T., Tamis-Holland, J.E., Alexander, J.H.,
Morrow, D.A., Baber, U., Mukherjee, D., Baker, H., et al. (2025) '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, 151, pp.
e00–e00. Available at: https://www.ahajournals.org/journal/circ
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