Clinical Update

ADAPTED FROM:

2025 ACC/AHA/ACEP/NAEMSP/SCAI
Guideline for the Management of Patients
with Acute Coronary Syndromes.

AHA Clinical Update PPTX

Table 1. CLASS (STRENGTH) OF RECOMMENDATION
CLASS 1 (STRONG) Benefit >>> Risk
LEVEL (QUALITY) OF EVIDENCE‡
LEVEL A
Applying Class of Suggested phrases for writing recommendations: • High-quality evidence‡ from more than 1 RCT

Recommendation
• Is recommended • Meta-analyses of high-quality RCTs
• Is indicated/useful/effective/beneficial • One or more RCTs corroborated by high-quality registry studies
• Should be performed/administered/other
and Level of • Comparative-Effectiveness Phrases†:
− Treatment/strategy A is recommended/indicated in preference to
LEVEL B-R
• Moderate-quality evidence‡ from 1 or more RCTs
(Randomized)

Evidence to treatment B
− Treatment A should be chosen over treatment B
• Meta-analyses of moderate-quality RCTs

Clinical Strategies,
LEVEL B-NR (Nonrandomized)
CLASS 2a (MODERATE) Benefit >> Risk
• Moderate-quality evidence‡ from 1 or more well-designed, well-

Interventions,
Suggested phrases for writing recommendations:
executed nonrandomized studies, observational studies, or registry
• Is reasonable
studies
• Can be useful/effective/beneficial

Treatments, or
• Meta-analyses of such studies
• Comparative-Effectiveness Phrases†:
− Treatment/strategy A is probably recommended/indicated in preference to LEVEL C-LD (Limited Data)

Diagnostic Testing
treatment B
− It is reasonable to choose treatment A over treatment B • Randomized or nonrandomized observational or registry studies
with limitations of design or execution

in Patient Care CLASS 2b (Weak)

Suggested phrases for writing recommendations:
Benefit ≥ Risk • Meta-analyses of such studies
• Physiological or mechanistic studies in human subjects
• May/might be reasonable LEVEL C-EO (Expert Opinion)
• May/might be considered
• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established • Consensus of expert opinion based on clinical experience.

CLASS 3: No Benefit (MODERATE) Benefit = Risk COR and LOE are determined independently (any COR may be paired with any LOE).
A recommendation with LOE C does not imply that the recommendation is weak. Many
Suggested phrases for writing recommendations: important clinical questions addressed in guidelines do not lend themselves to clinical
• Is not recommended trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a
particular test or therapy is useful or effective.
• Is not indicated/useful/effective/beneficial
• Should not be performed/administered/other * The outcome or result of the intervention should be specified (an improved
clinical outcome or increased diagnostic accuracy or incremental prognostic
information).
CLASS 3: Harm (STRONG) Risk > Benefit
† For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only),
Suggested phrases for writing recommendations: studies that support the use of comparator verbs should involve direct
comparisons of the treatments or strategies being evaluated.
• Potentially harmful
• Causes harm ‡ The method of assessing quality is evolving, including the application of
standardized, widely-used, and preferably validated evidence grading tools; and
• Associated with excess morbidity/mortality for systematic reviews, the incorporation of an Evidence Review Committee.
• Should not be performed/administered/other COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level
of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.

Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation.
Definition and Classifications
of Acute Coronary Syndromes
Biomarker
Unstable Angina
Negative

Biomarker
Non-Occlusive Positive NSTEMI
Thrombus ST Depression or T Wave Inversion
(May be electrically silent)

Biomarker
Positive STEMI
(May be negative if drawn too
early from symptom onset)
Occlusive
Thrombus ST Elevation

Abbreviations: NSTEMI indicates non-ST-elevation myocardial infarction; and STEMI, ST-elevation myocardial infarction.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 3
Pre-hospital Assessment and Management
Considerations for Suspected ACS
Suspected ACS

Evaluation by
Emergency Medical Services

Non-Diagnostic For STEMI 12-Lead ECG STEMI

Within 10 minutes of First Medical Contact

Transport to Local Immediate transfer to
Emergency Department PCI-capable hospital

Further in-hospital assessment of Goal of First Medical Contact to

confirmed or suspected ACS Serial ECGs Device Time ≤ 90 minutes

To detect potential ischemic changes, especially if clinical suspicion for ACS remains high

In patients with STEMI managed with primary PCI

each 30 minute delay is associated with 7.5% relative risk of 1-year death
Abbreviations: ACS indicates acute coronary syndrome; ECG, electrocardiogram;
STEMI, ST-elevation myocardial Infarction; and PCI, percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 4
Initial In-Hospital Assessment of Patients with
Confirmed or Suspected ACS
Focused History & Physical Examination

Suspected ACS

ECG Within 10 Minutes (Class 1) Obtain Cardiac Troponin (Class 1)

No STEMI Yes

Serial ECG Monitoring (Class 1) Evaluate For Reperfusion Therapy

Serial Cardiac Troponin (Class 1)

Intermediate Risk
Clinical Decision Pathway
Low Risk
Used To Define Risk
Using Initial and/or Subsequent Troponin Values at Presentation
High Risk or Criteria Met for NSTEMI

Abbreviations: ACS indicates acute coronary syndrome; ECG, electrocardiogram; and STEMI, ST-elevation myocardial infarction.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 5
Management of Patients Presenting with Cardiac Arrest
Following achievement of return of spontaneous circulation (ROSC)

Mental Status Awake Comatose Comatose Comatose

Presence of STEMI Yes Yes Yes No

Prognostic ~ 10% of patients

-- Favorable Unfavorable --
Features with STEMI
transferred by
PPCI Reasonable Immediate Coronary
EMS have an
Guideline PPCI PPCI After Individualized Angiography Not
out-of-hospital
Recommendation (Class 1) (Class 1) Assessment Recommended
cardiac arrest
(Class 2b) (Class 3: No Benefit)

Abbreviations: EMS indicates emergency medical services; PPCI, primary percutaneous coronary intervention;
and STEMI, ST- elevation myocardial infarction.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 6
Standard Medical Therapy for Acute Coronary Syndromes
Analgesic Treatment Options
Medication Route Considerations

Nitroglycerin • 0.4 mcg sublingual every 5 minutes for

• Avoid use in suspected RV infarction or SBP < 90 mm Hg
(SL) up to 3 doses

• Consider for persistent anginal pain after oral nitrate therapy

Nitroglycerin • Start at 10 mcg/min and titrate to pain
• Use if ACS is complicated by hypertension or flash pulmonary edema
(IV) relief and hemodynamic tolerability
• Avoid use in suspected RV infarction or SBP < 90 mm Hg

Morphine • 2-4 mg; may repeat if needed every 5-15 • Use for pain that is resistant to maximal anti-ischemic medications
(IV) minutes up to 10 mg total dose • May delay the effects of oral P2Y12 therapy

• Use for pain that is resistant to maximally tolerated anti-ischemic

Fentanyl • 25-50 mcg; may repeat if needed up to medications
(IV) 100 mcg total dose
• May delay the effects of oral P2Y12 therapy

Analgesic therapies provide symptomatic relief but have not been shown to improve clinical outcomes in ACS.
If ischemic symptoms persist despite efforts at pain control, consider urgent coronary angiography.

Abbreviations: ACS indicates acute coronary syndromes; IV, intravenous; RV, right ventricle; SBP, systolic blood pressure; and SL, sublingual.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 7
Antiplatelet Therapy: Aspirin During Hospitalization

Aspirin
COR RECOMMENDATIONS
In patients with ACS, an initial oral loading dose of aspirin,
1 followed by daily low-dose aspirin is recommended to reduce
death and MACE

Abbreviations: ACS indicates acute coronary syndrome; and MACE, major adverse cardiovascular event.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 8
Antiplatelet Therapy: Oral P2Y12 Inhibitors During
Hospitalization

P2Y12 Inhibitors
COR RECOMMENDATIONS
In patients with ACS, an oral P2Y12 inhibitor should be
1 administered in addition to aspirin to reduce MACE

3: In patients with a history of stroke or TIA, prasugrel should NOT

HARM be administered because of worse net clinical outcomes

Abbreviations: ACS indicates acute coronary syndrome; MACE, major adverse cardiovascular event; and TIA, transient ischemic attack.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 9
Oral P2Y12 Inhibitors: In-Hospital Management
of Patients with NSTE-ACS

In patients with NSTE- In patients with NSTE- In patients with NSTE- In patients with NSTE-ACS
ACS undergoing PCI, ACS who are managed ACS, clopidogrel is planned for an invasive
prasugrel or ticagrelor is without planned invasive recommended to reduce strategy with timing of
recommended to reduce evaluation, ticagrelor is MACE when prasugrel or angiography anticipated
MACE and stent recommended to reduce ticagrelor are not to be >24h, upstream
thrombosis. MACE. available, cannot be treatment with
(Class 1) (Class 1) tolerated, or are clopidogrel or ticagrelor
contraindicated. may be considered to
(Class 1) reduce MACE.
(Class 2b)

Abbreviations: ACS, acute coronary syndrome; MACE, major adverse cardiovascular event;
NSTE, non-ST elevation; STEMI, ST-elevation myocardial infarction.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 10
Oral P2Y12 Inhibitors: In-Hospital Management
of Patients with STEMI

In patients with STEMI In patients with STEMI In patients with STEMI

managed with PPCI, managed with PPCI, managed with fibrinolytic
prasugrel or ticagrelor clopidogrel is recommended to therapy, clopidogrel
should be administered reduce MACE and stent should be administered
to reduce MACE and stent thrombosis when prasugrel or concurrently to reduce
thrombosis. ticagrelor are not available, death and MACE.
(Class 1) cannot be tolerated, or are (Class 1)
contraindicated.
(Class 1)

Abbreviations: ACS, acute coronary syndrome; MACE, major adverse cardiovascular event;
NSTE, non-ST elevation; STEMI, ST-elevation myocardial infarction.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 11
Antiplatelet Therapy: Intravenous P2Y12

Intravenous Cangrelor: Rapid and potent platelet

inhibitory effects with restoration of platelet function
occurring within one hour of drug discontinuation
Intravenous P2Y12 Inhibitors Consider in clinical scenarios where:
COR RECOMMENDATIONS Absorption of orally administered P2Y12
Among patients with ACS undergoing PCI inhibitors is impaired or not possible
who have not received a P2Y12 inhibitor,
2b Patients requiring CABG or other surgery early
intravenous cangrelor may be reasonable
to reduce periprocedural ischemic events after PCI when prolonged discontinuation of a
P2Y12 inhibitor is not thought to be safe
The transition from intravenous to oral P2Y12 inhibition is
an important consideration to ensure adequate platelet
inhibition upon completion of cangrelor infusion

Abbreviations: ACS, acute coronary syndrome; and PCI, percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 12
Antiplatelet Therapy: Intravenous Glycoprotein
IIb/IIa Inhibitors

Intravenous Glycoprotein IIb/IIIa Inhibitors

COR RECOMMENDATIONS

In patients with ACS undergoing PCI with large thrombus burden,

no-reflow, or slow flow, adjunctive use of an intravenous or
2a
intracoronary glycoprotein IIb/IIIa inhibitor is reasonable to
improve procedural success and reduce infarct size

In patients with ACS, glycoprotein IIb/IIIa inhibitors should not be

3: HARM administered routinely due to lack of ischemic benefit and
increased risk of bleeding

Abbreviations: ACS indicates acute coronary syndrome; and PCI, percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 13
Parenteral Anticoagulation
PCI Not Planned PCI Planned
COR RECOMMENDATIONS COR RECOMMENDATIONS

In patients with NSTE-ACS, intravenous unfractionated In patients with ACS undergoing PCI, intravenous UFH is
1 1 useful to reduce ischemic events.
heparin (UFH) is useful to reduce ischemic events.

In patients with NSTE-ACS in whom an early invasive approach In patients with STEMI undergoing PCI, bivalirudin is useful
1 as an alternative to UFH to reduce mortality and bleeding
1 is not anticipated, either enoxaparin or fondaparinux are
recommended alternatives to UFH.
In patients with NSTE-ACS undergoing PCI, bivalirudin may
2b be reasonable as an alternative to UFH to reduce bleeding
Coronary Revascularization
In patients with ACS, intravenous enoxaparin may be
COR RECOMMENDATIONS 2b considered as an alternative to UFH at the time of PCI to
reduce ischemic events
In patients with ACS undergoing coronary revascularization
(CABG or PCI) in the same admission, parenteral 3: In patients with ACS, fondaparinux should NOT be used to
1 anticoagulation should be continued until revascularization to
HARM support PCI because of the risk of catheter thrombosis
reduce ischemic events.

Abbreviations: ACS indicates acute coronary syndrome; NSTE, non-ST elevation; PCI, percutaneous coronary intervention;
STEMI, ST elevation myocardial infarction; and UFH, unfractionated heparin.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 14
Parenteral Anticoagulation

STEMI:
Anticoagulant Therapy Treated
with Fibrinolytic Therapy

Plan for Invasive Approach or

Revascularization?

Yes No

Continue Parenteral Enoxaparin

Anticoagulation for the (Class 1)
Duration of Hospital stay
(Maximum of 8 Days) or Fondaparinux is a
Until Revascularization is recommended alternative
Performed (Class 1)
(Class 1)

Abbreviations: STEMI indicates ST elevation myocardial infarction.

Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 15
Lipid Management
Statin Therapy
COR RECOMMENDATIONS
In patients with ACS, high-intensity statin therapy is recommended to reduce the risk of Non-Statin
1 MACE Lipid Lowering Therapies:
In patients with ACS who are already on maximally tolerated statin therapy with LDL
1 ≥70 mg/dL (≥1.8 mmol/l), adding a non-statin lipid lowering agent is recommended to
Ezetimibe
further reduce the risk of MACE
In patients with ACS who are already on maximally tolerated statin therapy with LDL 55-
2a 69 mg/dL (≥1.4- <1.8 mmol/l), adding a non-statin lipid lowering agent is reasonable to
PCSK9 Inhibitors
reduce the risk of MACE
(monoclonal
In patients with ACS, the concurrent initiation of ezetimibe in combination with antibodies or
2b maximally tolerated statin may be considered to reduce the risk of MACE
inclisiran)

Statin Intolerance
COR RECOMMENDATIONS Bempedoic Acid

In patients with ACS who are statin intolerant, non-statin lipid lowering therapy is
1 recommended to lower LDL and reduce the risk of MACE

Abbreviations: ACS indicates acute coronary syndrome; LDL, low-density lipoprotein, and MACE, major adverse cardiovascular event.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 16
Beta Blocker Therapy and Renin-Angiotensin
System Inhibitors

All patients without contraindication** COR RECOMMENDATIONS

In high-risk patients with ACS (LVEF ≤40%, HTN,

diabetes mellitus or STEMI with anterior location),
Early (<24 h) initiation of oral beta blocker 1 an oral ACEi or an ARB is indicated to reduce all-
therapy to reduce risk of reinfarction and cause mortality and MACE.
ventricular arrhythmias (Class 1)
In patients with ACS and LVEF ≤ 40%, and with HF
**Contraindications to Beta Blocker Therapy 1 symptoms and/or diabetes mellitus, a MRA is
– Acute HF indicated to reduce all-cause mortality and MACE.
– Low output state or risk for CS
– PR > 0.24 ms
In ACS patients who are not considered high risk, an
– 2nd or 3rd degree AVB without a pacemaker 2a oral ACEi or an ARB is reasonable to reduce MACE.
– Severe bradycardia
– Active bronchospasm

Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ACS, acute coronary syndrome; ARB, angiotensin receptor
blocker; CS, cardiogenic shock; HF, heart failure; HTN, hypertension; LVEF, left ventricular ejection fraction; MACE, major adverse
cardiovascular event; MRA, mineralocorticoid receptor antagonist; and STEMI, ST-elevation myocardial infarction.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 17
 ACS
Primary PCI in STEMI
CS or hemodynamic instability
present?
Emergency revascularization of culprit vessel
Yes by PCI or CABG is indicated to improve survival
No (Class 1)

Time from symptom onset

< 12 hours >24 hours

12-24 hours
Presence of ongoing ischemia, severe HF
Hospital Transfer Required?
or life-threatening arrhythmia?
No Yes Yes No
Primary PCI is reasonable
Perform primary Perform primary Primary PCI is Primary PCI should
to improve clinical
PCI with goal FMC PCI with goal FMC reasonable to not be performed
outcomes
to device activation to device activation improve clinical due to lack of
(Class 2a)
< 90 minutes < 120 minutes outcomes benefit
(Class 1) (Class 1) (Class 2a) (Class 3: No Benefit)

Abbreviations: ACS indicates acute coronary syndrome; CS, cardiogenic shock; CABG, coronary artery bypass graft; FMC, first medical contact;
HF, heart failure; STEMI, ST-elevation myocardial infarction; and PCI, percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 18
Reperfusion at Non-PCI Capable Hospitals
STEMI present?

Fibrinolytic therapy should not be

No administered due to risk of hemorrhagic
Yes stroke or major noncerebral bleeding

Contraindication to fibrinolytics?
Yes No

Transfer to a PCI-capable hospital Time from symptom onset

for primary PCI to reduce MACE
< 12 hours 12-24 hours
(Class 1)
Delay of > 120 minutes Transfer to a PCI-capable
No for time from FMC to hospital for primary PCI is
primary PCI? reasonable to reduce
infarct size and MACE
Yes (Class 2a)
Administer fibrinolytics
to reduce MACE
(Class 1)
Abbreviations: FMC indicates first medical contact; MACE, major adverse cardiovascular event; STEMI, ST-elevation myocardial infarction;
and PCI, percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 19
Coronary Angiography and PCI After Fibrinolytic Therapy

STEMI treated with

fibrinolytic therapy
**Clinical Signs of
Failed Reperfusion:
Transfer to PCI-capable center
- Ongoing ischemic
immediately after fibrinolytic therapy
symptoms
(Class 1)
- Persistent ST-segment
Suspected failed reperfusion** elevation (<50% resolution
of ST-segment elevation
Yes No in anterior leads or <70%
in inferior leads
Immediate angiography - Hemodynamic or
Early angiography
with rescue PCI is electrical instability
between 2-24hrs with
recommended to reduce
intent to perform PCI to
the risk of death or
reduce rates of death or
recurrent MI
MI (Class 1)
(Class 1)

Abbreviations: Mi indicates myocardial infarction; STEMI, ST-elevation myocardial infarction; and PCI, percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 20
 Rationale and Timing for a Routine Invasive or
Selective Invasive Approach
Choice and Timing of Management Strategy in NSTEACS

Unstable/Very Lower Risk NSTEACS

High-Risk NSTEACS Intermediate Risk NSTEACS
High-Risk Patient
Any of: Any of: Any of:
Any of:
• Cardiogenic shock • GRACE risk score >140 • GRACE risk score <109
• GRACE Risk Score 109-140
• Signs or symptoms of HF, • Steeply rising Tn values on • TIMI Risk Score <2
including new/worsening • Absence of ongoing ischemic
serial testing despite
mitral regurgitation or acute symptoms • Absence of ongoing ischemic symptoms
optimized medical therapy
pulmonary edema • Stable or down-trending Tn • Tn <99th percentile (ie, unstable angina)
• Ongoing dynamic
• Refractory angina values
ST-segment changes • No dynamic ST-segment changes
• Hemodynamic or electrical
instability (eg, sustained VT or
VF) Routine Invasive (Class 1) Routine Invasive (Class 1) Routine Invasive or Selective Invasive (Class 1)

Immediate Invasive Strategy Coronary Angiography Before Coronary Non-Invasive Risk

(<2h, Class 1) Coronary Angiography <24h
Hospital Discharge (<72h) Angiography Before Stratification During
(Class 2a)
(Class 2a) Hospital Discharge Hospitalization or
(Class 2a) Recurrent Symptoms
Abbreviations: GRACE indicates Global Registry of Acute Coronary Events; HF, heart failure; NSTEACS, non-ST-segment elevation acute
coronary syndrome; Tn, troponin; TIMI, Thrombolysis in Myocardial Infarction; VF, ventricular fibrillation; and VT, ventricular tachycardia.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 21
Catheterization Lab Considerations in ACS

Radial approach is preferred to

a femoral approach to reduce
bleeding, vascular complications
and mortality (1)

For coronary stent implantation in Among patients

left main artery or in complex with STEMI
lesions, intracoronary imaging undergoing PPCI,
(ICI) with intravascular imaging manual aspiration
ultrasound (IVUS) or optical thrombectomy
coherence tomography (OCT) is should not be
recommended for procedural performed
guidance to reduce ischemic routinely
events (1) (3: No benefit)
Source: Arneja Heart Institute

Abbreviations: ACS indicates acute coronary syndrome; STEMI, ST-elevation myocardial infarction;
and PPCI, primary percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 22
Management of the Non-Infarct-Related Artery in STEMI

STEMI with multivessel CAD

Cardiogenic shock Hemodynamically stable

Routine PCI of a non-infarct-related

CABG Low complexity MVD
artery at the time of PPCI should not
be performed because of the higher
risk of death or renal failure After successful PCI of infarct related artery,
(Class 3: Harm) After successful PCI of the infarct- PCI of non-infarct-related arteries is
related artery, elective CABG for recommended to reduce rates of death or MI
significantly stenosed non-infarct- (Class 1)
related arteries involving the LAD or
left main is reasonable (Class 2a)
Multi-vessel PCI of significantly
stenosed non-infarct-related arteries
at the time of PPCI may be preferred
over a staged approach (Class 2b)

Abbreviations: CAD indicates coronary artery disease; CABG, coronary artery bypass graft; STEMI, ST-elevation myocardial infarction;
PCI, percutaneous coronary intervention; and PPCI, primary percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 23
Management of the Non-Culprit Lesions in NSTE-ACS

NSTEMI with multivessel CAD

Cardiogenic shock Hemodynamically stable

Routine PCI of a non-infarct-related Mode of revascularization (CABG or multivessel PCI)

artery at the time of PPCI should should be based on the disease complexity and
not be performed because of the patients’ comorbidities* (Class 1)
higher risk of death or renal failure
(Class 3: Harm)
Multivessel PCI CABG

PCI of significantly stenosed non-infarct-related arteries *CABG preferred over multivessel

PCI in the following situations:
recommended to reduce risk of death or MI and improve
significant left main disease,
angina-related quality of life (Class 1) complex left main disease with
severe left ventricular dysfunction,
Physiological assessment of non-culprit stenosis may be complex or diffuse CAD, diabetes
considered to guide revascularization decisions. (Class 2b) and involvement of the LAD

Abbreviations: CAD indicates coronary artery disease; CABG, coronary artery bypass graft; NSTE-ACS, non-ST-elevation acute coronary syndrome;
PCI, percutaneous coronary intervention; and PPCI, primary percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 24
Revascularization in ACS with Cardiogenic Shock

COR RECOMMENDATIONS

In patients with ACS and CS or hemodynamic instability, emergency

1 revascularization of the culprit vessel by PCI or with CABG is indicated to
improve survival, irrespective of time from symptom onset.

In patients with ACS complicated by CS, routine PCI of a non-infarct

3:
artery at the time of PPCI should not be performed because of the higher
HARM risk of death or renal failure.

Abbreviations: ACS indicates acute coronary syndrome; CABG, coronary artery bypass graft; STEMI, CS, cardiogenic shock;
PCI, percutaneous coronary intervention; and PPCI, primary percutaneous coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 25
Electrical Complications and Prevention of Sudden
Cardiac Death After ACS

Ventricular Ventricular Ventricular

Bradyarrhythmias
Arrhythmias Arrhythmias Arrhythmias

In patients post MI, In patients post ACS, ICD In patients early after MI, In patients presenting with an acute MI
implantable cardioverter- implantation is usefulness of a temporary with sustained evidence of second-
defibrillator implantation reasonable in patients wearable cardioverter- degree Mobitz type II atrioventricular
is recommended in with clinically relevant defibrillator is uncertain block, high-grade atrioventricular block,
selected patients with an ventricular arrhythmias in patients with an LVEF alternating bundle-branch block, or
LVEF ≤40% at least 40 more than 48 hours and ≤35% to improve survival. third-degree atrioventricular block
days post MI and at least within 40 days post MI to (Class 2b) (persistent or infranodal), permanent
90 days post improve survival.* pacing is indicated.†
revascularization to (Class 2a) (Class 1)
reduce death.*
(Class 1)

*Adapted from 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
†Adapted from 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay

Abbreviations: ACS indicates acute coronary syndrome; ICD, implantable cardioverter defibrillator;
LVEF, left ventricular ejection fraction; and MI, myocardial infarction.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 26
 In-Hospital Issues in the Management of ACS
Cardiac Intensive Care Unit Telemetry Monitoring Echocardiogram Blood Transfusions

ACS and any of the following: In ACS patients, In patients with ACS, an In patients with ACS and
• Ongoing angina telemetry monitoring is assessment of LVEF is acute or chronic anemia,
• Hemodynamic instability recommended to reduce recommended prior to blood transfusion to achieve
• Uncontrolled cardiovascular events hospital discharge to a hemoglobin level ≥10 g/dL
arrhythmias with duration determined guide therapy and for may be reasonable to reduce
• Suboptimal reperfusion by cardiac risk. risk stratification. cardiovascular events.
• Cardiogenic shock
(Class 1) (Class 1) (Class 2b)
Admit to CICU
(Class 1)

Abbreviations: ACS indicates acute coronary syndrome; CICU, cardiac intensive care unit; and LVEF, left ventricular ejection fraction.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 27
Patient Education, Lifestyle Modifications,
Medication, and Follow-up Care
Hospital admission Lifestyle modifications Medications Follow-up care

Follow-up appointments
Education about CAD, Smoking cessation Antithrombotic therapy
diagnostic tests, Lipid-lowering therapy
procedural results Other therapies as Cardiology
appropriate
Healthy diet Cardiac
Return to physical rehabilitation
and sexual activity, Annual influenza
work and travel Regular exercise vaccination
Additional testing

Symptom management and psychosocial support

Abbreviations: CAD indicates coronary artery disease.

Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 28
Post-discharge Follow-up and
Systems of Care Coordination

Clinical Assessment Patient/Caregiver Assessment

• Address comorbidities and risk factors • Assess patient/caregiver capacity for
• Assess; self care
o Ongoing ischemic symptoms • Provide verbal and written educational
o Bleeding risk information related to self care
o Need for repeat echocardiogram, staged PCI
o Vaccination status like influenza • Use teach-back method to confirm
understanding of self-care, medication
• Perform medication reconciliation Communication regimen and adherence
Patient centered
Share decision-making
Social Determinants of Health
• Assess and address barriers to obtaining Referrals
medications • Confirm referral to cardiac
• Refer to pharmacy assistance programs rehabilitation
or social worker as appropriate • Provide educational materials
• Assess and address barriers to attending related to cardiac rehabilitation
cardiac rehabilitation

Abbreviations: PCI indicates percutaneous coronary intervention.

Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 29
Cardiac Rehabilitation for Patients Post-ACS

Post-ACS Discharge Planning

Exercise
Training

Center-based Cardiac Rehabilitation

Nutrition program (Class 1)
Education Referral to
Cardiac
Psycho- Rehab
social Home-based Cardiac Rehabilitation
Support program (Class 2a)

Medication  Lowers morbidity & mortality

Review
 Reduces recurrent CV events &
hospital readmissions
 Improves functional status & QoL

Abbreviations: ACS indicates acute coronary syndrome; CV, cardiovascular; and QoL, quality of life.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 30
 DAPT Strategies in the First 12 Months Post-Discharge
ACS

High Bleeding
Default Strategy Bleeding Reduction Strategies Post PCI
Risk Post PCI*
Index Admission
Triple Therapy
DAPT + OAC DAPT DAPT
DAPT
1 week (ASA + (ASA + P2Y12
(ASA + ticagrelor) Discontinue ASA
DAPT ≥12 mo ticagrelor/prasugrel) inhibitor)
1-4 wk post PCI
1 month
ASA + P2Y12 Discontinue ASA Descalate potency of Stop ASA or P2Y12
inhibitor 1-3 mo post PCI inhibitor >1 mo post PCI
SAPT + OAC P2Y12 inhibitor
3 months (ticagrelor/ >1 mo post PCI
prasugrel SAPT
SAPT Clopidogrel
6 months preferred post PCI) DAPT
monotherapy and
Ticagrelor OAC ASA or P2Y12
(Class 1)
monotherapy ASA + clopidogrel inhibitor
9 months
(Class 1) monotherapy
(Class 1)
(Class 2b) (Class 2b)
12 months
*High bleeding risk discussed in supportive text 5 and outlined in Table 22.

Abbreviations: ACS indicates acute coronary syndrome; ASA, aspirin; DAPT, dual antiplatelet therapy;
OAC, oral anticoagulant; PCI, percutaneous coronary intervention; SAPT, single antiplatelet therapy.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 31
Antiplatelet Therapy in Patients on
Anticoagulation Post-Discharge
Indication for
Anticoagulation

DOAC
if no contraindication

DOAC + DAPT post PCI

DC ASA after
1-4 weeks

DOAC + P2Y12i* for 12 months (1)

*preferably clopidogrel
Abbreviations: AF indicates atrial fibrillation; ACS, acute coronary syndrome; ASA, aspirin; DAPT, dual antiplatelet therapy;
DC, discontinue; DOAC, direct-acting oral anticoagulant; PCI, percutaneous coronary intervention; and VTE, venous
thromboembolism.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 32
Reassessment of Lipid Levels Post-Discharge

Post-ACS Hospitalization

Lipid-lowering therapy initiation

or dose adjustment

4-8 weeks

Re-assess LDL-C with fasting lipid panel (Class 1)

LDL-C remains LDL-C at

high target or low

Early intensification of Continue current

therapy therapy

Abbreviations: ACS indicates acute coronary syndrome; and LDL-C, low-density lipoprotein cholesterol.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 33
Immunization Management

COR RECOMMENDATIONS

In patients with ACS without a contraindication, annual

1 influenza vaccination is recommended to reduce the risk of
death and MACE.

Abbreviations: ACS indicates acute coronary syndrome; and MACE, major adverse cardiovascular event.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 34
 Role of coronary angiography in
Future Directions patient subgroups:
• Post-arrest & comatose state
Risk Scoring to • STEMI with late presentation
Guide Treatment
Strategies
• De-escalation of
antiplatelet therapy Transitioning Contemporary Duration of
In-Hospital telemetry monitoring
• Anticoagulation for from Acute to Optimal P2Y12
anterior wall infarction Chronic Coronary Monitoring and inhibitor loading
• Management of post-MI Syndromes Management Novel drug therapies
pericarditis EVIDENCE of ACS
GAPS
• Multivessel PCI versus culprit-only
• Selection of patients for MCS in NSTEMI
Best Use of Treatment of
• Strategies to reduce vascular
Mechanical Multi-Vessel • Determination based on
complications
Circulatory Coronary Artery
angiography vs physiology
• Timing of placement & duration Support Devices • Cases with complex anatomy
of support Disease
(staged CABG)

Abbreviations: ACS indicates acute coronary syndromes; CABG, coronary artery bypass grafting MCS, mechanical circulatory support; MI,
myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction; and PCI, percutaneous
coronary intervention.
Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 35
Acknowledgments
Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott
Antman in developing this translational learning product in support of the
2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for the Management of
Patients with Acute Coronary Syndromes.

Dr. Waseem Farooq Dr. Parth Patel

Dr. Ivana Garza Dr. Warren Tai
Dr. Kathryn Harris Dr. Aradhana Verma

The American Heart Association requests this electronic slide deck be cited as follows:
Farooq, W., Garza, I., Harris, K., Patel, P., Tai, W., Verma, A., Reyna, G. G., Bezanson, J. L., & Antman, E. M.
(2025). AHA Clinical Update; Adapted from: [PowerPoint slides]. Retrieved from the 2025
AHA/ACC/ACEP/NAEMSP/SCAI Guideline for the Management of Patients with Acute Coronary Syndromes.
Science News - Professional Heart Daily | American Heart Association

Rao, S.V., et al. 2025 AHA/ACC/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. 36