2025 ACC/AHA Guidelines for Acute Coronary Syndrome Management: Key Points for Emergency Physicians
The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guidelines for ACS management provide critical updates that emergency physicians should implement immediately to reduce mortality and improve outcomes in patients with acute coronary syndromes.
Initial Management and Antiplatelet Therapy
Aspirin Administration
- All patients with suspected ACS should receive an immediate loading dose of aspirin (162-325 mg) as soon as possible, followed by daily low-dose aspirin (75-100 mg) 1
- Non-enteric coated aspirin should be chewed for faster onset of action
- For patients unable to take oral medication, rectal or intravenous administration are acceptable alternatives
P2Y12 Inhibitor Selection
- In patients with STEMI managed with primary PCI, prasugrel or ticagrelor should be administered to reduce MACE and stent thrombosis (Class 1, Level B-R) 1
- Clopidogrel is recommended only when prasugrel or ticagrelor are unavailable, cannot be tolerated, or are contraindicated
- For STEMI managed with fibrinolytic therapy, clopidogrel should be administered concurrently (Class 1, Level A) 1
- Prasugrel is contraindicated in patients with history of stroke or TIA due to worse clinical outcomes (Class 3: Harm) 1
P2Y12 Inhibitor Dosing
| Agent | Loading Dose | Maintenance Dose |
|---|---|---|
| Clopidogrel | 300-600 mg (600 mg preferred for PCI) | 75 mg daily |
| Prasugrel | 60 mg | 10 mg daily (5 mg if <60 kg or ≥75 years) |
| Ticagrelor | 180 mg | 90 mg twice daily |
Anticoagulation Strategy
- All patients with ACS should receive parenteral anticoagulation regardless of initial treatment strategy 1
- For NSTE-ACS, intravenous unfractionated heparin (UFH) is useful to reduce ischemic events (Class 1, Level B-R)
- For STEMI undergoing PCI, bivalirudin is a useful alternative to UFH to reduce mortality and bleeding (Class 1, Level B-R)
- Fondaparinux should NOT be used to support PCI due to risk of catheter thrombosis (Class 3: Harm) 1
Reperfusion Strategies for STEMI
Primary PCI
- Remains the preferred reperfusion strategy when available within 120 minutes of first medical contact 2
Fibrinolytic Therapy
- For patients with STEMI treated with fibrinolytic therapy, transfer to a PCI-capable center immediately after fibrinolytic therapy is recommended (Class 1, Level A) 1
- Early angiography between 2-24 hours with intent to perform PCI is recommended to reduce death or MI (Class 1, Level B-R)
- For suspected failed reperfusion after fibrinolytic therapy, immediate angiography with rescue PCI is recommended (Class 1, Level B-R) 1
Symptom Management in ACS
Pain Control
- Nitroglycerin and opiates remain effective for pain management but should be used judiciously 1
- Nitroglycerin: Start at 0.3-0.4 mg SL every 5 minutes (up to 3 doses) or IV at 10 μg/min titrated to pain relief
- Morphine: 2-4 mg IV, may repeat every 5-15 minutes up to 10 mg (monitor for delayed P2Y12 absorption)
- Fentanyl: 25-50 μg IV, may repeat if needed up to 100 μg
Important Cautions
- Avoid nitrates with recent PDE5 inhibitor use (within 12h of avanafil, 24h of sildenafil/vardenafil, or 48h of tadalafil)
- Avoid nitrates in suspected RV infarction or SBP <90 mmHg
- Avoid NSAIDs for pain management in ACS patients
Special Considerations
Patients on Oral Anticoagulants
- For patients with ACS who also require oral anticoagulation (e.g., atrial fibrillation):
- Initial triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) should be limited
- Discontinue aspirin after 1-4 weeks while maintaining P2Y12 inhibitor plus anticoagulant 1
- Clopidogrel is the preferred P2Y12 inhibitor when combined with anticoagulation
Bleeding Risk Reduction
- A proton pump inhibitor is recommended for patients at increased risk of gastrointestinal bleeding 1
- Consider shorter duration of DAPT in patients at high bleeding risk
Key Takeaways for Emergency Physicians
- Immediate aspirin administration (162-325 mg) is critical for all suspected ACS patients
- Choose the appropriate P2Y12 inhibitor based on presentation and planned management strategy
- Ensure appropriate anticoagulation is initiated early
- Arrange rapid transfer to PCI-capable centers for STEMI patients
- Monitor for and manage complications including bleeding
By implementing these evidence-based recommendations from the 2025 ACC/AHA guidelines, emergency physicians can significantly improve outcomes for patients presenting with acute coronary syndromes.