AHA, ACC Update Guidelines for Acute Coronary Syndrome Management

ACC and AHA publish updated guidelines for managing acute coronary syndrome.

Image Credit: inthasone - stock.adobe.com

New guideline updates for acute coronary syndrome management were published by the American College of Cardiology (ACC) and the American Heart Association (AHA) in JACC and Circulation.1 The latest evidence to enhance patient care and outcomes was incorporated into the “2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes.”

Key Updates in the 2025 Guideline

The guideline introduces notable updates including refined recommendations for dual antiplatelet therapy to balance bleeding risk, a stronger emphasis on the radial artery approach for percutaneous coronary intervention to reduce complications, and updated guidance on cardiogenic shock management, outlining new treatment considerations. Secondary prevention, including lipid management and cardiac rehabilitation, is also reinforced to reduce long-term cardiovascular risks.

Dual Antiplatelet Therapy Recommendations

Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor, remains a cornerstone of acute coronary syndrome treatment to prevent recurrent myocardial infarction.2 The guideline reinforces that:

• Patients with low bleeding risk should continue DAPT for at least 12 months post hospital discharge
• Patients at higher bleeding risk may require modified strategies based on individual assessments

Radial Artery Approach for Percutaneous Coronary Intervention

The guideline strongly favors the radial approach over the femoral approach for percutaneous coronary intervention, as it reduces bleeding, vascular complications, and mortality. Additionally, intravascular imaging is now a Class 1, Level A recommendation to guide these procedures.

Use of Ticagrelor or Prasugrel Over Clopidogrel

The guideline now explicitly recommends ticagrelor or prasugrel over clopidogrel in patients undergoing percutaneous coronary intervention due to their superior efficacy in reducing major adverse cardiovascular events.

Cardiogenic Shock Management

Cardiogenic shock, a life-threatening condition affecting approximately 10% of patients with acute myocardial infarction, is associated with a 40% to 50% early mortality rate. The guideline highlights that prompt revascularization remains a Class 1 recommendation and new therapies, such as the microaxial flow pump, may be considered based on patient-specific risks and benefits.

Complete Revascularization Strategy

For patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI), the guideline now emphasizes a strategy of complete revascularization rather than just treating the culprit lesion, with considerations for multivessel percutaneous coronary intervention or coronary artery bypass grafting based on disease complexity and comorbidities.

Microaxial Flow Pump for Cardiogenic Shock

Recent trial data were highlighted in the guideline for supporting the use of the microaxial flow pump in selected patients with cardiogenic shock. However, cautions about associated risks like bleeding, limb ischemia, and renal failure were also noted.

Red Blood Cell Transfusion for Anemia

The guideline indicated it may be reasonable to transfuse red blood cells to maintain hemoglobin at 10 g/dL in patients with acute coronary syndrome who have acute or chronic anemia and are not actively bleeding.

Secondary Prevention Strategies

To reduce long-term complications and improve recovery, the guideline includes the following recommendations:

• A fasting lipid panel should be conducted 4 to 8 weeks after starting or adjusting lipid-lowering therapy to assess effectiveness (Class 1)
• Patients with acute coronary syndrome on a maximally tolerated statin with low-density lipoprotein (LDL-C) of at least 70 mg/dL should add a nonstatin lipid-lowering agent such as ezetimibe, evolocumab, alirocumab, inclisiran, or bempedoic acid (Class 1)
• Even for patients with LDL-C levels of 55 to 69 mg/dL, adding a nonstatin may be beneficial (Class 2a)
• Outpatient cardiac rehabilitation referral prior to hospital discharge is strongly recommended to reduce mortality, myocardial infarction recurrence, and hospital readmissions while improving quality of life (Class 1)

The guideline was developed in collaboration with and endorsed by the American College of Emergency Physicians, the National Association of EMS Physicians, and the Society for Cardiovascular Angiography and Interventions.1

"Patients with [acute coronary syndrome] are at the highest risk for cardiovascular complications both acutely and chronically, which emphasizes the importance of staying up-to-date on the most recent evidence," Sunil V. Rao, MD, FACC, FSCAI, chair of the guideline writing committee and director of Interventional Cardiology at NYU Langone Health, said in the news release. "With appropriate management, we can improve outcomes both in the hospital and over the long term."

References

1. ACC, AHA issue new acute coronary syndromes guideline. News release. American Heart Association. February 27, 2025. https://newsroom.heart.org/news/acc-aha-issue-new-acute-coronary-syndromes-guideline

2. Kumbhani D, Cibotti-Sun M, Moore M. 2025 acute coronary syndromes guideline-at-a-glance. J Am Coll Cardiol. Published online February 27, 2025. doi:10.1016/j.jacc.2025.01.018