Overview
This lecture reviews the major updates in the 2025 ACC/AHA guidelines for managing acute coronary syndromes (ACS), focusing on changes in revascularization, antiplatelet therapy, lipid management, and mechanical circulatory support.
Revascularization Strategies
- Complete revascularization with PCI is recommended for stable STEMI patients with multivessel disease after primary PCI, to reduce death, MI, and improve quality of life.
- Immediate multivessel PCI during primary PCI is preferred over staged PCI in selected STEMI patients with low-complexity lesions.
- In NSTEMI, PCI of significant non-culprit lesions is now Class 1, either at index or staged, if not for CABG and without left main stenosis.
- In both STEMI and NSTEMI with cardiogenic shock, routine PCI of non-infarct arteries during primary PCI is harmful (Class 3).
Dual Antiplatelet Therapy (DAPT)
- At least 12 months of DAPT (aspirin + P2Y12 inhibitor) is Class 1 for ACS patients not at high bleeding risk.
- Ticagrelor or prasugrel is now preferred over clopidogrel for ACS patients undergoing PCI (Class 1).
- Early transition (at 1 month) to ticagrelor monotherapy is recommended after initial DAPT for those tolerating therapy.
- For high bleeding risk, switching to single antiplatelet therapy at 1 month (aspirin or P2Y12) is reasonable.
- In patients on anticoagulation, aspirin should be stopped after 1–4 weeks post-PCI, continuing with clopidogrel plus anticoagulant.
- Unguided de-escalation from potent to less potent P2Y12 inhibitor may be considered after 1 month.
Lipid Management
- High-intensity statin is recommended for all ACS patients; ezetimibe may be started concurrently (Class 2B).
- If LDL ≥70 mg/dL despite maximal statin, add non-statin therapy (Class 1).
- If LDL 55–69 mg/dL, consider non-statin agents (Class 2A).
- For statin intolerance, add non-statin LDL-lowering therapy (Class 1).
- Lipid profiles should be reassessed in 4–8 weeks post-discharge.
Mechanical Circulatory Support
- Impella (microaxial flow pump) may be reasonable in selected STEMI patients with severe/refractory cardiogenic shock (Class 2B).
- Routine use of intra-aortic balloon pump (IABP) or VA-ECMO is not recommended in MI-related cardiogenic shock (Class 3).
- IABP/VA-ECMO may still be used as bridge-to-surgery or in specific high-risk settings.
Key Terms & Definitions
- ACS (Acute Coronary Syndrome) — spectrum of conditions from unstable angina to myocardial infarction.
- PCI (Percutaneous Coronary Intervention) — non-surgical technique to open narrowed coronary arteries.
- DAPT (Dual Antiplatelet Therapy) — combination of aspirin and a P2Y12 inhibitor to prevent clotting.
- MACE (Major Adverse Cardiovascular Events) — composite endpoint including death, MI, and stroke.
- Impella — microaxial flow pump used for temporary mechanical circulatory support.
- CABG (Coronary Artery Bypass Grafting) — surgical revascularization for coronary artery disease.
Action Items / Next Steps
- Review full text of 2025 ACC/AHA ACS guidelines for details.
- Assess and record patient lipid profiles 4–8 weeks after discharge.
- Apply updated DAPT and revascularization strategies in clinical scenarios.
- Refer ACS patients for cardiac rehabilitation post-discharge.