What are the initial treatment recommendations for patients presenting with acute coronary syndrome (ACS) according to the 2025 American Heart Association (AHA) guidelines?

From the Guidelines

The initial treatment for patients presenting with acute coronary syndrome (ACS) according to the 2025 American Heart Association (AHA) guidelines should include dual antiplatelet therapy (DAPT) with aspirin and an oral P2Y12 inhibitor for at least 1 year to reduce major adverse cardiac events (MACE) in patients who are not at high bleeding risk. The 2025 AHA guidelines, as outlined in the study by 1, provide recommendations for the management of patients with ACS, including DAPT strategies in the first 12 months postdischarge. Some key points to consider in the initial treatment of ACS include:

• DAPT with aspirin and an oral P2Y12 inhibitor should be administered for at least 1 year to reduce MACE in patients who are not at high bleeding risk, as recommended by the guidelines with a Class of Recommendation (COR) of 1 and a Level of Evidence (LOE) of A 1.
• In patients with ACS who have tolerated DAPT with ticagrelor, transition to ticagrelor monotherapy ≥1 month post PCI may be useful to reduce bleeding risk, with a COR of 2b and an LOE of B-R 1.
• Patients at high risk of gastrointestinal bleeding should receive a proton pump inhibitor (PPI) in combination with DAPT, oral anticoagulants, or both to reduce the risk of bleeding, with a COR of 2b and an LOE of B-R 1.
• De-escalation of DAPT (switching from ticagrelor or prasugrel to clopidogrel) after 1 month may be reasonable in patients with ACS undergoing PCI to reduce bleeding risk, with a COR of 2b and an LOE of B-R 1.
• Transition to single antiplatelet therapy (aspirin or P2Y12 inhibitor) after 1 month may be reasonable in patients with ACS undergoing PCI who are at high bleeding risk, with a COR of 2b and an LOE of B-R 1. These recommendations are based on the most recent and highest quality evidence available, as outlined in the 2025 AHA guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Treatment Recommendations for Acute Coronary Syndrome (ACS)

The initial treatment recommendations for patients presenting with acute coronary syndrome (ACS) according to the available guidelines and studies are as follows:

• Aspirin is recommended for all patients with a suspected acute coronary syndrome (ACS) unless contraindicated 2.
• Addition of a second antiplatelet (ie, dual antiplatelet therapy) (eg, clopidogrel, ticagrelor, or prasugrel) also is recommended for most patients 2.
• Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux 2.
• Proton pump inhibitors are recommended to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher than average risk of gastrointestinal bleeding 2.
• Other medical therapies should include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin and morphine (to relieve chest pain), and oxygen 2.

Revascularization Strategies

For patients with an ST-segment elevation myocardial infarction, percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible 2.

• However, fibrinolytic therapy should be used first if PCI will be delayed for more than 120 minutes 2.
• For non-ST-segment elevation ACS, PCI is recommended; fibrinolytic therapy typically is not recommended 2.
• If patients require coronary artery bypass graft to reestablish coronary artery flow, it ideally is delayed 3 to 7 days after admission unless the patient has cardiogenic shock, life-threatening arrhythmias, three-vessel disease (with 70% occlusion each), greater than 50% left main coronary artery occlusion, unsuccessful or complicated PCI, or mechanical complications (eg, valve rupture) 2.

Dual Antiplatelet Therapy (DAPT)

Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) reduces cardiovascular event rates after ACS 3.

• The duration of DAPT should be based on patient characteristics, including the risk of bleeding and myocardial ischemia 3.
• If bleeding risk is low, prolonged DAPT may be considered, although the optimal duration of prolonged DAPT beyond 1 year is not well established 3.
• If bleeding risk is high, shorter duration (ie, 3-6 months) of DAPT may be reasonable 3.