This article explained the 2025 ACC/AHA guidelines with key updates in ACS management. We invite you to explore these essential changes that can support your clinical decisions and enhance patient care.

The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a revised clinical practice guideline for the therapy of acute coronary syndromes (ACS), which is supported by the most robust evidence and incorporates updated pharmacological and procedural interventions.

Individuals with ACS have the greatest risk for cardiovascular problems, both in the short and long term, underscoring the necessity of remaining informed about the latest information outlined in this recommendation.

This revised ACC/AHA/Multisociety ACS Guideline, in conjunction with the 2021 ACC/AHA/SCAI Coronary Artery Revascularisation Guideline, supersedes the 2016 Focused Update on the Duration of Dual Antiplatelet Therapy in Patients with Coronary Artery Disease. In order to hasten the implementation of the guideline, this Guideline-at-a-Glance focuses on its suggestions that could alter current practices.

The distribution of American College of Cardiology (ACC) guidelines is a comprehensive initiative coordinated by the Solution Set Oversight Committee to guarantee the incorporation of guideline content across the ACC’s clinical policy, education, registry, membership, and advocacy activities. For each guideline, a distinct ACC Guideline distribution Workgroup is established to shape the distribution strategy and build instruments to aid in the implementation of essential practice improvements.

Key Points to Consider

The key takeaways below are extracted straight from the ACC/AHA/Multisociety ACS Guideline. They signify the most significant alterations in these recommendations relative to prior guidelines and address recognised deficiencies in clinical practice.

1. Dual antiplatelet treatment is advised for those with acute coronary syndrome (ACS). Ticagrelor or prasugrel is preferred over clopidogrel for individuals with acute coronary syndrome (ACS) having percutaneous coronary intervention (PCI). In patients with non-ST-segment elevation acute coronary syndrome planned for an invasive approach with angiography time beyond 24 hours, upstream therapy with clopidogrel or ticagrelor may be contemplated to mitigate significant adverse cardiovascular events.

2. Dual antiplatelet treatment, including aspirin and an oral P2Y12 inhibitor, is recommended for a minimum of 12 months as the standard approach for patients with acute coronary syndrome who are not at elevated risk of bleeding. A variety of treatments exist to mitigate bleeding risk in individuals with acute coronary syndrome who have had percutaneous coronary intervention and necessitate antiplatelet therapy:

1. A proton pump inhibitor is advised for patients at risk of gastrointestinal bleeding.
2. For patients who have successfully tolerated dual antiplatelet therapy with ticagrelor, a transition to ticagrelor monotherapy is recommended at least one month post-PCI.
3. In patients necessitating long-term anticoagulation, it is recommended to discontinue aspirin 1 to 4 weeks after PCI while continuing a P2Y12 inhibitor, preferably clopidogrel.

3. High-intensity statin treatment is advised for all patients with acute coronary syndrome, with the possibility of concurrently initiating ezetimibe. A non-statin lipid-lowering drug (e.g., ezetimibe, evolocumab, alirocumab, inclisiran, bempedoic acid) is advised for patients on the maximum tolerable statin dosage with a low-density lipoprotein cholesterol level of ≥70 mg/dL (1.8 mmol/L). In this high-risk group, it is prudent to enhance lipid-lowering medication if the low-density lipoprotein cholesterol level is between 55 and <70 mg/dL (1.4 to <1.8 mmol/L) and the patient is currently receiving the maximum tolerable dose of a statin.

4. In patients with non-ST-segment elevation acute coronary syndrome at moderate or high risk of ischemic events, an invasive strategy aimed at revascularisation is advised during hospitalisation to mitigate significant adverse cardiovascular events. In patients with non-ST-segment elevation acute coronary syndrome at low risk for ischemic events, a routine invasive or selective invasive strategy with further risk stratification is advised to identify individuals who may need revascularisation and to mitigate significant adverse cardiovascular events.

5. Two procedural strategies are advised for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI): a) the radial approach is favored over the femoral approach to minimise bleeding, vascular complications, and mortality; and b) intracoronary imaging is recommended to facilitate PCI in patients with ACS presenting complex coronary lesions.

6. A comprehensive revascularisation strategy is advised for individuals with ST-segment elevation myocardial infarction or non-ST-segment elevation acute coronary syndrome. The selection of revascularisation technique (i.e., coronary artery bypass graft surgery versus multivessel percutaneous coronary intervention) in non-ST-segment elevation.

7. The management of acute coronary syndrome and multivessel disease should be determined by the intricacy of the coronary artery disease and associated comorbidities. Percutaneous coronary intervention (PCI) for severe nonculprit stenoses in patients with ST-segment elevation myocardial infarction may be conducted in a single session or staged, with a preference for executing multivessel PCI in one treatment. In patients with acute coronary syndrome and cardiogenic shock, emergent revascularisation of the culprit artery is warranted; however, routine percutaneous coronary intervention of non-infarct-related arteries during the procedure is not advised.

8. The microaxial flow pump appears to be a reasonable tool for reducing mortality in certain patients with cardiogenic shock due to acute myocardial infarction, according to one study. Nevertheless, problems like haemorrhage, limb ischemia, and renal failure are more prevalent with the microaxial flow pump than with standard therapy. Consequently, meticulous consideration of vascular access and the gradual reduction of support is essential to effectively weigh the advantages against the hazards.

9. Administering red blood cell transfusions to sustain a haemoglobin level of 10 g/dL may be appropriate for individuals with acute coronary syndrome and acute or chronic anaemia who are not experiencing active haemorrhage.

10. Post-discharge, emphasis on secondary prevention is essential. A fasting lipid panel is advised 4 to 8 weeks following the commencement or modification of cholesterol-lowering treatment. Referral to cardiac rehabilitation is advised, including the possibility for home-based programs for individuals who are unable or unable to attend in person. 

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.