Written by Mary Marschner
Spoon Feed
This 2025 Acute Coronary Syndrome (ACS) guideline focuses on careful coordination of complex EMS-hospital communication and multi-specialty collaboration to provide safe, comprehensive discharge.
2025 ACS – a cute synopsis
This guideline is a comprehensive review of ACS management, which covers both ST-elevation MI (STEMI) and non ST-elevation MI (NSTEMI) patients.
First, STEMI. The goals in descending order of priority are:
- Cath time via a radial approach < 90 minutes with successful stent placed.
- Load on prasugrel or ticagrelor (over clopidogrel) and continue dual antiplatelet therapy (DAPT) for likely one year.
- All of these patients should be risk stratified, receive an echocardiogram, and be placed on telemetry overnight.
For STEMIs, in addition to a radial approach, with intravascular ultrasound or fractional flow reserve (FFR), stents will often be placed in non-infarct-related arteries, as it reduces the risk of death/myocardial infraction and improves quality of life.
Next, high-risk NSTEMI. The goal is:
- Anticoagulate them with a heparin drip (or enoxaparin or fondaparinux as alternatives).
- Consider them for PCI if high risk, and if low risk, for an inpatient stress or coronary CTA to successfully risk-stratify.
- PCI or medical therapy; they must leave with either.
Before discharge:
- Get the LDL < 70 with high-intensity statins or low-intensity statins plus ezetimibe/PCSK9 inhibitors if intolerant.
- Arrange follow-up with PCP, cardiology, and cardiac rehab.
For the outpatient provider:
- Set a time for DAPT de-escalation.
- On prasugrel/ASA? Drop the ASA after 1-3 months.
- On oral anticoagulation and DAPT? Stop the ASA after 1-4 weeks and continue clopidogrel.
- Lastly, flu shot, always.
How does this change my practice?
This update was super organized and helpful for managing ACS. For me, it is paradigm-pivoting, as it provides instructions on how to facilitate discussions with emergency room, cardiology, and primary care colleagues to focus on more effective interdisciplinary care for the treatment of my ACS patients.
Source
2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025 Apr;151(13):e771-e862. doi: 10.1161/CIR.0000000000001309. Epub 2025 Feb 27. Erratum in: Circulation. 2025 Apr;151(13):e865. doi: 10.1161/CIR.0000000000001328. PMID: 40014670
