What are the current management guidelines for Acute Coronary Syndrome (ACS) in 2025?

2025 ACS Management Guidelines

The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guidelines for Acute Coronary Syndrome (ACS) management recommend dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, with ticagrelor or prasugrel preferred over clopidogrel for patients undergoing percutaneous coronary intervention (PCI), and complete revascularization strategy for both STEMI and NSTE-ACS patients. 1

Antiplatelet Therapy

Initial Management

• Dual antiplatelet therapy (DAPT) is recommended for all ACS patients, consisting of aspirin and a P2Y12 inhibitor 1
• For patients undergoing PCI, ticagrelor or prasugrel is recommended in preference to clopidogrel to reduce major adverse cardiovascular events 1
• In patients with non-ST-segment elevation ACS scheduled for invasive strategy with angiography >24 hours away, upstream treatment with clopidogrel or ticagrelor may be considered 1
• For patients with history of stroke or TIA, prasugrel should be avoided due to increased risk of cerebrovascular events 1, 2

Duration and Modifications

• DAPT with aspirin and a P2Y12 inhibitor is indicated for at least 12 months as the default strategy in patients not at high bleeding risk 1
• For patients at risk of gastrointestinal bleeding, a proton pump inhibitor is recommended 1
• In patients who have tolerated DAPT with ticagrelor, transition to ticagrelor monotherapy is recommended ≥1 month after PCI 1
• For patients requiring long-term anticoagulation, aspirin discontinuation is recommended 1-4 weeks after PCI with continued use of a P2Y12 inhibitor (preferably clopidogrel) 1

Revascularization Strategies

• A strategy of complete revascularization is recommended in both STEMI and NSTE-ACS patients 1
• The choice between CABG and multivessel PCI should be based on coronary disease complexity and comorbidities 1
• For STEMI patients, PCI of significant non-culprit stenoses can be performed in a single procedure or staged, with some preference toward single-procedure multivessel PCI 1
• In ACS patients with cardiogenic shock, emergency revascularization of the culprit vessel is indicated; however, routine PCI of non-infarct-related arteries during the procedure is not recommended 1
• Radial approach is preferred over femoral approach for PCI to reduce bleeding, vascular complications, and death 1
• Intracoronary imaging is recommended to guide PCI in patients with complex coronary lesions 1

Management of Special Situations

Cardiogenic Shock

• In selected patients with cardiogenic shock related to acute myocardial infarction, use of a microaxial flow pump is reasonable to reduce mortality 1
• Careful attention to vascular access and weaning of support is important as complications such as bleeding, limb ischemia, and renal failure are higher with microaxial flow pumps compared to usual care 1

Anemia Management

• Red blood cell transfusion to maintain a hemoglobin of 10 g/dL may be reasonable in patients with ACS and acute or chronic anemia who are not actively bleeding 1

Antiplatelet Management for CABG

• For patients requiring CABG, P2Y12 inhibitors should be discontinued as follows 1:
  • Clopidogrel: 5 days before elective CABG; at least 24 hours before urgent CABG
  • Prasugrel: 7 days before elective CABG; at least 24 hours before urgent CABG
  • Ticagrelor: 3-5 days before elective CABG; at least 24 hours before urgent CABG
• P2Y12 inhibitors should be resumed after surgery when bleeding risk is not excessive (typically 24-72 hours) 1

Glycoprotein IIb/IIIa Inhibitors

• Routine administration of glycoprotein IIb/IIIa inhibitors is not recommended due to lack of ischemic benefit and increased bleeding risk 1
• However, in patients undergoing PCI with large thrombus burden, no-reflow, or slow flow, adjunctive use of intravenous or intracoronary glycoprotein IIb/IIIa inhibitor is reasonable 1

Secondary Prevention

• After discharge, focus on secondary prevention is fundamental 1
• A fasting lipid panel is recommended 4-8 weeks after initiating or adjusting lipid-lowering therapy 1
• Referral to cardiac rehabilitation is recommended, with home-based programs as an option for patients unable or unwilling to attend in person 1
• Shared decision-making between clinicians and patients is important to enhance adherence to guideline recommendations 1

Important Considerations and Pitfalls

• Clopidogrel effectiveness varies based on CYP2C19 genotype; patients who are CYP2C19 poor metabolizers have decreased active metabolite exposure and diminished platelet inhibition 3
• Consider alternative P2Y12 inhibitors in patients identified as CYP2C19 poor metabolizers 3
• Avoid concomitant use of strong CYP2C19 inhibitors (such as omeprazole or esomeprazole) with clopidogrel as they significantly reduce its antiplatelet activity 3
• For patients with high bleeding risk, shorter DAPT duration (3-6 months) may be reasonable 2
• Guidelines should not replace clinical judgment; management should be tailored based on individual patient characteristics 1