From the Guidelines
The 2025 Acute Coronary Syndromes guidelines prioritize personalized approaches to pharmacotherapy and intervention timing to improve patient outcomes while balancing bleeding risks. The guidelines now recommend dual pathway inhibition with low-dose rivaroxaban (2.5mg twice daily) plus aspirin for high-risk patients with stable coronary artery disease, as seen in recent studies 1. For NSTEMI patients, routine early invasive strategy timing has been refined to within 24 hours of presentation, based on the latest evidence from the American Heart Association 1. Key updates include:
- More aggressive LDL-C targets (<55 mg/dL) and recommendation of PCSK9 inhibitors for patients not reaching goals on maximum tolerated statins, as supported by the 2023 chronic coronary disease guideline-at-a-glance 1
- Colchicine (0.5mg daily) is now recommended for secondary prevention in selected post-MI patients
- Expanded indications for SGLT2 inhibitors and GLP-1 receptor agonists in patients with diabetes and established cardiovascular disease
- Preferred P2Y12 inhibitors remain ticagrelor or prasugrel over clopidogrel, with duration recommendations now more individualized based on bleeding risk, as emphasized in the 2023 focused update on adult advanced cardiovascular life support 1. These changes reflect growing evidence that more targeted approaches can improve outcomes while balancing bleeding risks in acute coronary syndrome management. The guidelines also stress the importance of team-based, patient-centered care, considering social determinants of health and incorporating shared decision-making, as highlighted in the 2023 chronic coronary disease guideline-at-a-glance 1. Regular physical activity is substantially encouraged, as it reduces long-term risk of cardiovascular events, according to the latest recommendations 1.
From the FDA Drug Label
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From the Research
Updates to Acute Coronary Syndromes Guidelines
- The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes incorporates new evidence since the 2013 and 2014 guidelines, including recommendations on dual antiplatelet therapy (DAPT) and antiplatelet regimens 2.
- Dual antiplatelet therapy, consisting of aspirin and a P2Y12 inhibitor, reduces cardiovascular event rates after acute coronary syndrome (ACS) 3.
- The choice of P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) and the duration of DAPT depend on the patient's risk of bleeding and ischemia 3, 4.
Dual Antiplatelet Therapy
- DAPT is recommended for at least 12 months for patients with ACS, but the optimal duration of prolonged DAPT beyond 1 year is not well established 3.
- For patients with a high risk of bleeding, a shorter duration (3-6 months) of DAPT may be reasonable 3.
- P2Y12 inhibitor monotherapy after 3-month DAPT may be a viable alternative to conventional DAPT, with a lower risk of bleeding and comparable efficacy 5.
Patient-Specific Considerations
- Patients at higher risk of bleeding include those 65 years old or older, with low body weight (BMI <18.5), diabetes, or prior bleeding, or those taking oral anticoagulants 3.
- Clinicians should avoid prescribing prasugrel to patients with a history of stroke or transient ischemic attack, or to patients older than 75 years or who weigh less than 60 kg 3.
- Personalized DAPT strategies, including guided de-escalation of P2Y12 inhibition and shortening DAPT duration, may help mitigate bleeding risk while retaining antithrombotic efficacy 4.