ACS Management Guidelines 2025 New Updates Key points

AHA ACC Guidelines

Acute coronary syndrome (ACS) encompasses a spectrum of clinical manifestations, including ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina. The diagnosis of ACS is based on a combination of clinical presentation, electrocardiogram (ECG) findings, and cardiac biomarker elevation. Patients with suspected ACS should undergo immediate ECG and troponin measurement. Serial ECGs and biomarker measurements may be necessary to establish the diagnosis.

In patients with STEMI, prompt reperfusion therapy is crucial to restore coronary blood flow and minimize myocardial damage. Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy if it can be performed promptly by an experienced team. Fibrinolytic therapy is an alternative when primary PCI is not feasible. In patients with NSTEMI or unstable angina, an early invasive strategy with coronary angiography and PCI is recommended for those at high risk of adverse outcomes.

Antiplatelet therapy is a cornerstone of ACS management. Aspirin should be administered promptly to all patients with suspected ACS, followed by a P2Y12 inhibitor, such as clopidogrel, prasugrel, or ticagrelor. The choice of P2Y12 inhibitor depends on the patient's ischemic and bleeding risk. Anticoagulation therapy, such as unfractionated heparin, low-molecular-weight heparin, or fondaparinux, is also recommended.

High-intensity statin therapy is recommended for all patients with ACS to reduce the risk of recurrent ischemic events. Beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are also recommended for patients with ACS, particularly those with reduced left ventricular function or heart failure. Lifestyle modifications, including smoking cessation, dietary changes, and regular exercise, are essential for secondary prevention.

Risk stratification is crucial in ACS management. The GRACE risk score can be used to estimate the risk of in-hospital and long-term mortality. Patients at high risk of adverse outcomes may benefit from more aggressive therapeutic strategies. In patients with ACS, careful monitoring for complications, such as heart failure, arrhythmias, and bleeding, is essential.

Long-term management of patients with ACS involves secondary prevention strategies, including antiplatelet therapy, statin therapy, beta-blockers, and lifestyle modifications. Regular follow-up with a cardiologist is essential to monitor for recurrent ischemic events and adjust therapy as needed. Adherence to guideline-recommended therapies can significantly improve outcomes in patients with ACS.

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