What changes in the 2025 Acute Coronary Syndrome (ACS) guidelines should alter emergency medicine practice?

Key Changes in the 2025 ACS Guidelines for Emergency Medicine Practice

The most significant changes in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Acute Coronary Syndrome guidelines that should alter emergency medicine practice include the use of microaxial intravascular flow pumps in selected patients with STEMI and severe cardiogenic shock, and the recommendation against routine PCI of non-infarct-related arteries during primary PCI in patients with cardiogenic shock.

Revascularization in Cardiogenic Shock

Culprit Vessel Only Approach

• In patients with ACS complicated by cardiogenic shock, the 2025 guidelines now explicitly recommend against routine PCI of non-infarct-related arteries at the time of primary PCI 1
• This recommendation is classified as Class 3: Harm (Level B-R), indicating potential harm due to higher risk of death or renal failure
• Emergency revascularization should focus on the culprit vessel only by PCI or CABG, regardless of time from symptom onset (Class 1, Level B-R) 1

Mechanical Circulatory Support Updates

• New recommendation: In selected patients with STEMI and severe or refractory cardiogenic shock, insertion of a microaxial intravascular flow pump is now considered reasonable (Class 2a, Level B-R) 1
• The guidelines specifically recommend against routine use of intra-aortic balloon pumps (IABP) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) due to lack of survival benefit (Class 3: No Benefit, Level B-R) 1
• For mechanical complications of ACS, short-term mechanical circulatory support devices are reasonable for hemodynamic stabilization as a bridge to surgery (Class 2a, Level B-NR) 1

Multivessel PCI Approach in Non-Shock ACS

• The 2025 guidelines incorporate evidence from recent trials showing benefit of multivessel PCI in elderly patients with multivessel disease and ACS 1
• The FIRE trial demonstrated that multivessel PCI reduced the risk of major adverse cardiac events (MACE) and mortality in elderly patients (median age 80 years) with multivessel disease 1
• The SMILE trial showed that multivessel PCI conducted in a single procedure (rather than staged) reduces risk of MACE at 1 year 1
• The BIOVASC trial demonstrated that multivessel PCI in a single procedure was noninferior to staged PCI 1

Early ECG and Risk Stratification

• The guidelines emphasize early ECG acquisition within 10 minutes of first medical contact 2
• Computer-assisted ECG interpretation is permitted but must be used in conjunction with physician/trained provider interpretation 2
• Risk stratification using validated tools like GRACE and TIMI Risk Scores is recommended to guide management decisions 2

Antiplatelet Therapy Updates

• Stronger preference for ticagrelor or prasugrel over clopidogrel for ACS patients undergoing PCI 2
• Specific recommendations for ticagrelor monotherapy ≥1 month after PCI to reduce bleeding risk while maintaining anti-ischemic protection 2
• Aspirin loading dose (162-325mg) followed by daily maintenance dose of 75-100mg remains recommended 2

Practical Implementation for Emergency Medicine

1. For cardiogenic shock patients:

   • Focus on rapid revascularization of the culprit vessel only
   • Consider microaxial intravascular flow pump for selected patients with severe or refractory shock
   • Avoid routine use of IABP or VA-ECMO
   • Reserve multivessel PCI for non-shock patients

2. For multivessel disease without shock:

   • Consider complete revascularization strategy including non-culprit lesions
   • Single-stage multivessel PCI may be preferred over staged procedures in appropriate patients

3. For antiplatelet therapy:

   • Prioritize ticagrelor or prasugrel over clopidogrel when possible
   • Consider bleeding risk reduction strategies such as ticagrelor monotherapy ≥1 month after PCI

Caveats and Pitfalls

• Patient selection for microaxial flow pump use is critical - the guidelines do not specify exact criteria, but this likely includes patients with persistent hypotension despite inotropes/vasopressors and evidence of end-organ hypoperfusion
• The recommendation against multivessel PCI in cardiogenic shock may seem counterintuitive but is based on evidence showing harm
• Emergency physicians should coordinate closely with interventional cardiology for optimal timing and approach to revascularization
• While the guidelines provide stronger evidence for single-stage multivessel PCI in non-shock patients, individual patient factors must still be considered