What are the American Heart Association (AHA) 2025 guidelines for managing Acute Coronary Syndrome (ACS)?

2025 AHA Guidelines for Managing Acute Coronary Syndrome

The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes recommends a strategy of complete revascularization for patients with STEMI or NSTE-ACS, with preference for ticagrelor or prasugrel over clopidogrel in patients undergoing PCI, and a radial approach over femoral access to reduce bleeding complications and mortality. 1

Diagnosis and Initial Evaluation

Classification of ACS

• ACS includes three clinical conditions:
  • Unstable angina (transient myocardial ischemia without myonecrosis)
  • NSTEMI (partial/intermittent coronary occlusion with myocardial damage)
  • STEMI (complete coronary occlusion with transmural infarction) 1

Initial Diagnostic Approach

• ECG within 10 minutes of first medical contact (FMC) 1
• STEMI criteria: New ST-elevation ≥1 mm in ≥2 contiguous leads (except V2-V3); for V2-V3: ≥2 mm in men ≥40 years, ≥2.5 mm in men <40 years, ≥1.5 mm in women 1
• NSTE-ACS findings: ST-depression ≥0.5 mm in ≥2 contiguous leads and/or T-wave inversion >1 mm in ≥2 contiguous leads 1

Cardiac Biomarkers

• High-sensitivity troponin (hs-cTn) preferred with sampling at 1-2 hours from ED arrival
• For conventional troponin assays, sampling timeframe extends to 3-6 hours
• When using a single hs-cTn value, it should be obtained ≥3 hours after symptom onset 1

Risk Stratification

Risk Assessment Tools

• GRACE Risk Score: Superior to subjective assessment for predicting death or MI in STEMI or intermediate-risk NSTE-ACS 1
• TIMI Risk Score: Well-validated for both STEMI and NSTE-ACS 1

Variables in Risk Scores

• GRACE: Age, Killip class, systolic BP, heart rate, ST-segment deviation, cardiac arrest, serum creatinine, cardiac biomarkers 1
• TIMI for NSTE-ACS: Age ≥65, ≥3 CAD risk factors, known stenosis ≥50%, ST deviation, ≥2 anginal events in 24h, aspirin use in prior 7 days, elevated cardiac markers 1

Management Strategies

STEMI Management

• Primary PCI should be performed within 90 minutes of FMC (120 minutes for transfers) 1
• Fibrinolysis if PCI not feasible within 120 minutes of FMC, with door-to-lysis goal <30 minutes 1
• Complete revascularization strategy recommended (including non-culprit lesions) 1
• PCI of non-culprit stenoses can be performed in a single procedure or staged 1

NSTE-ACS Management

• Routine invasive approach for high/intermediate-risk patients 1
• Selective invasive approach for lower-risk patients with noninvasive testing prior to discharge 1
• Immediate invasive strategy (<2 hours) for unstable patients (refractory angina, hemodynamic/electrical instability, acute HF) 1

Antiplatelet Therapy

• Dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitor for at least 12 months 1
• Ticagrelor or prasugrel preferred over clopidogrel for ACS patients undergoing PCI 1, 2
• Prasugrel specifically recommended for patients not at high bleeding risk due to faster onset and less genetic variability 2
• Contraindications for prasugrel: History of stroke/TIA, active bleeding, likely urgent CABG; caution in patients ≥75 years 2

Procedural Considerations

• Radial approach preferred over femoral to reduce bleeding, vascular complications, and death 1
• Intracoronary imaging recommended to guide PCI in complex lesions 1

Cardiogenic Shock Management

• Early recognition and rapid revascularization associated with increased survival 1
• Microaxial flow pump reasonable in selected patients to reduce death, but with higher risk of bleeding, limb ischemia, and renal failure 1
• Emergency revascularization of culprit vessel indicated, but routine PCI of non-infarct arteries not recommended in shock 1

Post-Discharge Care

Secondary Prevention

• Cardiac rehabilitation recommended for all ACS patients 1
• Fasting lipid panel 4-8 weeks after initiating/adjusting lipid-lowering therapy 1
• Bleeding risk reduction strategies:
  • Proton pump inhibitor for GI bleeding risk
  • Ticagrelor monotherapy ≥1 month after PCI
  • Aspirin discontinuation 1-4 weeks after PCI with continued P2Y12 inhibitor (preferably clopidogrel) for patients requiring anticoagulation 1

Discharge Planning

• Medication reconciliation including prescription for sublingual nitroglycerin
• Assessment of self-care capacity and barriers to medication adherence
• Referral to cardiac rehabilitation with consideration of home-based or hybrid options 1

Special Considerations

Red Blood Cell Transfusion

• Transfusion to maintain hemoglobin of 10 g/dL may be reasonable in ACS patients with acute/chronic anemia not actively bleeding 1

Electrical Complications

• Patients with cardiac arrest and STEMI who have been resuscitated should be transferred to a PPCI-capable center 1

Pitfalls to Avoid

• Delaying ECG beyond 10 minutes of presentation
• Relying on a single troponin value obtained too early after symptom onset
• Using risk scores as diagnostic tools rather than for risk stratification
• Failing to recognize cardiogenic shock early
• Neglecting complete revascularization in appropriate patients
• Using femoral approach when radial access is feasible
• Selecting clopidogrel when ticagrelor or prasugrel would be more appropriate
• Overlooking cardiac rehabilitation referral at discharge

The 2025 AHA guidelines emphasize early diagnosis, appropriate risk stratification, timely revascularization, optimal antiplatelet therapy, and comprehensive secondary prevention to improve outcomes in patients with acute coronary syndromes.