What is the diagnosis and treatment for Acute Coronary Syndrome (ACS) in 2025?

From the Guidelines

The diagnosis and treatment of Acute Coronary Syndrome (ACS) in 2025 should be based on the most recent guidelines, which emphasize the importance of rapid evaluation and management, including the use of antithrombotic therapy and revascularization strategies. The diagnosis of ACS is typically made based on a combination of clinical presentation, electrocardiogram (ECG) findings, and biomarker results. According to the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1, the clinical presentation of ACS can range from cardiac arrest to patients who are already pain-free at the time of presentation, with the leading symptom being acute chest discomfort described as pain, pressure, tightness, and burning. The ECG is a crucial diagnostic tool, with two main groups of patients being differentiated: those with persistent ST-segment elevation and those without. Patients with ST-segment elevation are generally treated with immediate reperfusion by primary percutaneous coronary intervention (PCI) or fibrinolytic therapy, while those without ST-segment elevation may require antithrombotic therapy and revascularization strategies. The 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1 provide further guidance on the management of NSTE-ACS, including the use of aspirin, parenteral anticoagulation, and P2Y12 inhibitors such as ticagrelor or prasugrel. However, the most recent guidelines from 2024 1 should be consulted for the latest recommendations on the management of chronic coronary syndromes, including the use of antianginal drugs, antithrombotic therapy, lipid-lowering drugs, and revascularization strategies. Some key points to consider in the diagnosis and treatment of ACS include:

• Rapid evaluation and management to reduce morbidity and mortality
• Use of antithrombotic therapy, including aspirin and P2Y12 inhibitors
• Revascularization strategies, including PCI and coronary artery bypass grafting (CABG)
• Importance of lifestyle changes, including diet, exercise, and smoking cessation
• Use of lipid-lowering drugs and other medications to reduce cardiovascular risk.

From the FDA Drug Label

The CURE study included 12,562 patients with ACS without ST-elevation (UA or NSTEMI) and presenting within 24 hours of onset of the most recent episode of chest pain or symptoms consistent with ischemia Patients were required to have either ECG changes compatible with new ischemia (without ST-elevation) or elevated cardiac enzymes or troponin I or T to at least twice the upper limit of normal. The number of patients experiencing the primary outcome (CV death, MI, or stroke) was 582 (9.3%) in the clopidogrel-treated group and 719 (11.4%) in the placebo-treated group, a 20% relative risk reduction (95% CI of 10% to 28%; p <0. 001) for the clopidogrel-treated group

The diagnosis of Acute Coronary Syndrome (ACS) is based on:

• ECG changes compatible with new ischemia (without ST-elevation)
• Elevated cardiac enzymes or troponin I or T to at least twice the upper limit of normal
• Symptoms consistent with ischemia

The treatment for ACS includes:

• Clopidogrel (300 mg loading dose followed by 75 mg once daily)
• Aspirin (75 to 325 mg once daily)
• Other standard therapies such as heparin 2

From the Research

Diagnosis of Acute Coronary Syndrome (ACS)

• The diagnosis of ACS begins with a thorough clinical assessment of a patient's presenting symptoms, electrocardiogram, and cardiac troponin levels as well as a review of past medical history 3.
• Chest discomfort at rest is the most common presenting symptom of ACS and affects approximately 79% of men and 74% of women presenting with ACS 4.
• Electrocardiography should be performed immediately (within 10 minutes of presentation) and can distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS) 4.
• High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI 4.

Treatment of Acute Coronary Syndrome (ACS)

• Aspirin is recommended for all patients with a suspected acute coronary syndrome (ACS) unless contraindicated 5.
• Addition of a second antiplatelet (ie, dual antiplatelet therapy) (eg, clopidogrel, ticagrelor, or prasugrel) also is recommended for most patients 5.
• Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux 5.
• For patients with STEMI, coronary catheterization and PCI within 2 hours of presentation reduces mortality, with fibrinolytic therapy reserved for patients without access to immediate PCI 4, 5.
• For high-risk patients with NSTE-ACS without contraindications, prompt invasive coronary angiography followed by percutaneous or surgical revascularization is associated with lower rates of death 4, 5.
• Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) reduces cardiovascular event rates after ACS 6.
• The duration of DAPT should be based on patient characteristics, including risk of bleeding and myocardial ischemia 6.

Management of ACS

• Early risk stratification can assist clinicians in determining whether an early invasive management strategy or an initial conservative strategy should be pursued and can help determine appropriate pharmacologic therapies 3.
• Key components in the management of ACS include coronary revascularization when indicated; prompt initiation of dual antiplatelet therapy and anticoagulation; and consideration of adjuvant agents including β blockers, inhibitors of the renin angiotensin system, and HmG-coenzyme A reductase inhibitors 3.
• It is essential for clinicians to take an individualized approach to treatment and consider long-term safety and efficacy when managing patients with a history of ACS after hospital discharge 3.