What are the 2025 American College of Cardiology (ACC) guidelines for managing ST-Elevation Myocardial Infarction (STEMI)?

2025 ACC/AHA Guidelines for STEMI Management

Key Recommendations for STEMI Management

All communities should create and maintain regional systems of STEMI care that coordinate prehospital and hospital-based processes with the goal of reducing total ischemic time and improving survival in patients with STEMI. 1

Diagnosis and Initial Assessment

• A 12-lead ECG should be acquired and interpreted within 10 minutes of first medical contact (FMC) to identify STEMI 1
• STEMI is diagnosed by:
  • ST-segment elevation ≥1 mm in ≥2 contiguous leads on standard 12-lead ECG
  • Posterior leads (V7-V9) should be obtained when suspected left circumflex occlusion, particularly with isolated ST-segment depression ≥0.5 mm in leads V1-V3 1
• Serial ECGs should be performed when initial ECG is nondiagnostic but clinical suspicion remains high 1

Reperfusion Strategy

Primary PCI (PPCI) Recommendations

• In patients with STEMI presenting <12 hours after symptom onset, PPCI should be performed with a goal of FMC to device activation of ≤90 minutes, or ≤120 minutes in patients requiring hospital transfer. 1
• For patients with STEMI presenting 12-24 hours after symptom onset, PPCI is reasonable to improve clinical outcomes 1
• For patients presenting >24 hours with ongoing ischemia or life-threatening arrhythmia, PPCI is reasonable 1
• PPCI should NOT be performed in stable patients with totally occluded infarct artery >24 hours after symptom onset without evidence of ongoing ischemia, acute severe HF, or life-threatening arrhythmia 1

Prehospital Management

• Immediate EMS transport to a PCI-capable hospital for PPCI is the recommended triage strategy 1
• Early advance notification of the receiving PCI-capable hospital by EMS and activation of the cardiac catheterization team is recommended to reduce time to reperfusion 1
• Prehospital ECGs should be transmitted to the PPCI center while en route to help expedite coronary reperfusion 1

Cardiogenic Shock Management

• In patients with ACS and cardiogenic shock or hemodynamic instability, emergency revascularization of the culprit vessel by PCI or CABG is indicated regardless of time from symptom onset 1
• For every 10-minute delay in PPCI after 60 minutes from FMC, there are an additional 3-4 deaths per 100 patients with cardiogenic shock 1
• Patients with ACS and evidence of heart failure, ventricular arrhythmias, or cardiogenic shock should be triaged to a PCI-capable facility 1

Pharmacotherapy

• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for at least 12 months 2
• Aspirin loading dose (162-325mg) followed by daily maintenance dose of 75-100mg 2
• Ticagrelor or prasugrel are preferred over clopidogrel for ACS patients undergoing PCI 2
• High-intensity statins should be initiated regardless of baseline LDL-C levels 2
• In patients with AMI with LVEF ≤40% or HF symptoms:
  • ACE inhibitors reduce mortality and MACE 1
  • Mineralocorticoid receptor antagonist (eplerenone) reduces mortality and MACE 1

Systems of STEMI Care

The 2025 guidelines emphasize creating robust regional STEMI care systems that include:

1. Public education about calling 911 immediately for ischemic symptoms rather than self-transport
2. Efficient data collection without overburden
3. Data sharing between hospital departments and EMS agencies
4. Regular meetings to review data and drive process improvement 1

Common Pitfalls and Caveats

• Delay in ECG acquisition: Ensure ECG is obtained within 10 minutes of FMC
• Misdiagnosis: ST depression in anteroseptal leads (V1-V3) could indicate posterior STEMI; obtain posterior leads (V7-V9) when suspected 1
• Delayed reperfusion: For every 10-minute delay in PPCI after 60 minutes from FMC in cardiogenic shock patients, mortality increases significantly 1
• Inappropriate PPCI: PPCI should not be performed in stable patients with occluded infarct artery >24 hours after symptom onset without evidence of ongoing ischemia 1
• Medication errors: ACE inhibitors and ARBs should not be initiated concomitantly due to increased adverse events without added benefit 1

Special Considerations

• Patients with cardiac arrest and STEMI who have been resuscitated should be transferred to a PPCI-capable center 2
• For patients with STEMI where PPCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolysis therapy should be administered 3
• After fibrinolysis, patients should be transferred to a PCI center for early angiography 1
• Computer-assisted ECG interpretation is permitted but only in conjunction with physician/trained provider interpretation 2

By implementing these guidelines, healthcare systems can optimize STEMI care and improve patient outcomes through rapid diagnosis, appropriate triage, and timely reperfusion therapy.