JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO. -, 2025
ª 2025 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION,
AND THE AMERICAN HEART ASSOCIATION, INC.
PUBLISHED BY ELSEVIER
CLINICAL PRACTICE GUIDELINE
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
Developed in Collaboration With and Endorsed by the American College of Emergency Physicians,
National Association of EMS Physicians, and Society for Cardiovascular Angiography
and Interventions
Writing Sunil V. Rao, MD, FACC, FSCAI, Chair Debabrata Mukherjee, MD, MS, FACC, FAHA, MSCAI
Committee Michelle L. O’Donoghue, MD, MPH, FACC, FAHA, Vice Chair Elke Platz, MD, MS, FACEP
Members* Marc Ruel, MD, MPH, FACC, FAHA, Vice Chair Susan B. Promes, MD, MBA, FACEPk
Tanveer Rab, MD, FACC, MSCAI, JC Liaisony Sigrid Sandner, MD, MS
Jaqueline E. Tamis-Holland, MD, FACC, FAHA, FSCAI, Yader Sandoval, MD, FACC, FSCAI
JC Liaisony Rachel Schunder, MA{
Binita Shah, MD, MS
John H. Alexander, MD, MHS, FACC, FAHA Jason P. Stopyra, MD, MS#
Usman Baber, MD, MS, FACC, FSCAI Amy W. Talbot, MPH{
Heather Baker, EDDz Pam R. Taub, MD, FACC
Mauricio G. Cohen, MD, FACC, FSCAI Marlene S. Williams, MD, FACC**
Mercedes Cruz-Ruiz, CHWIz
Leslie L. Davis, PHD, RN, ANP-BC, FACC, FAHA
James A. de Lemos, MD, FACC, FAHA *Writing committee members are required to recuse themselves from
voting on sections to which their specific relationships with industry may
Tracy A. DeWald, PHARMD, MHS, BCPS-AQ CARDIOLOGY
apply; see Appendix 1 for detailed information.
Islam Y. Elgendy, MD, FACC, FAHA, FSCAI yACC/AHA Joint Committee on Clinical Practice Guidelines liaison.
Dmitriy N. Feldman, MD, FACC, FSCAIx zLay stakeholder/patient representative.
Abhinav Goyal, MD, MHS, FACC, FAHA xSociety for Cardiovascular Angiography and Interventions representative.
kAmerican College of Emergency Physicians representative.
Ijeoma Isiadinso, MD, MPH, FACC
{ACC/AHA joint staff representative.
Venu Menon, MD, FACC, FAHA #National Association of EMS Physicians representative.
David A. Morrow, MD, MPH, FACC, FAHA **ACC/AHA Joint Committee on Performance Measures representative.
This document was approved by the American College of Cardiology Clinical Policy Approval Committee and the American Heart Association Science
Advisory and Coordinating Committee in October 2024, the American College of Cardiology Science and Quality Committee in October 2024, and the
American Heart Association Executive Committee in November 2024.
The American College of Cardiology requests that this document be cited as follows: Rao SV, O’Donoghue ML, Ruel M, Rab T, Tamis-Holland JE,
Alexander JH, Baber U, Baker H, Cohen MG, Cruz-Ruiz M, Davis LL, de Lemos JA, DeWald TA, Elgendy IY, Feldman DN, Goyal A, Isiadinso I, Menon V,
Morrow DA, Mukherjee D, Platz E, Promes SB, Sandner S, Sandoval Y, Schunder R, Shah B, Stopyra JP, Talbot AW, Taub PR, Williams MS. 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. JACC. Published online February 27, 2025. https://doi.org/10.1016/j.jacc.2024.11.009
This article has been copublished in Circulation.
ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2024.11.009
Descargado para Alejandro Ramírez Ramírez () en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en abril
11, 2025. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2025. Elsevier Inc. Todos los derechos reservados.
,2 Rao et al JACC VOL. -, NO. -, 2025
2025 Acute Coronary Syndromes Management Guideline -, 2025:-–-
Peer Review Hani Jneid, MD, FACC, FAHA, FSCAI, Chair Noreen T. Nazir, MD, FACC
Committee Derek So, MD, MSc, FACC
Members Craig J. Beavers, PharmD, FACC, FAHA Matthew Tomey, MD, FACC, FAHA, FSCAI
Theresa Beckie, PhD, RN, FAHA Frederick Welt, MD, FACCx
Jim Blankenship, MD, MACC
Deborah Diercks, MD, FACC jjAmerican College of Emergency Physicians representative.
xSociety for Cardiovascular Angiography and Interventions
Bruce Lo, MDjj
representative.
Clauden Louis, MD, FACC
Faisal M. Merchant, MD, FACC
ACC/AHA Joint Catherine M. Otto, MD, FACC, FAHA, Chair W. Schuyler Jones, MD, FACC
Committee On Sunil V. Rao, MD, FACC, FSCAI, Chair-Elect Sadiya S. Khan, MD, MSc, FACC, FAHA
Clinical Practice Joshua A. Beckman, MD, MS, FAHA, FACC, Prateeti Khazanie, MD, FAHAyy
Guidelines Immediate Past Chairyy Michelle M. Kittleson, MD, FACC, FAHA
Members Venu Menon, MD, FACC, FAHA
Anastasia Armbruster, PharmD, FACC Debabrata Mukherjee, MD, MS, FACC, FAHA, MSCAI
Vanessa Blumer, MD, FACC Latha Palaniappan, MD, MS, FACC, FAHAyy
Leslie L. Davis, PhD, RN, ANP-BC, FACC, FAHA Tanveer Rab, MD, FACC, MSCAIyy
Lisa de las Fuentes, MD, MS, FAHAyy Garima Sharma, MBBS, FACC, FAHA
Anita Deswal, MD, MPH, FACC, FAHAyy Daichi Shimbo, MD
Victor A. Ferrari, MD, FACC Jacqueline E. Tamis-Holland, MD, FACC, FAHA, FSCAIyy
Stephen E. Fremes, MD, FACC Y. Joseph Woo, MD, FACC, FAHAyy
Mario Gaudino, MD, FACC, FAHA Boback Ziaeian, MD, PhD, FACC, FAHA
Adrian F. Hernandez, MD, FAHAyy
Hani Jneid, MD, FACC, FAHA yyFormer ACC/AHA Joint Committee on Clinical Practice Guidelines
member; current member during this writing effort.
Heather M. Johnson, MD, MS, FACC, FAHA
ABSTRACT
AIM The “2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes” incor-
porates new evidence since the “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction” and the
corresponding “2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes” and
the “2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial
Infarction.” The “2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes”
and the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” retire and replace, respectively, the “2016 ACC/AHA
Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease.”
METHODS A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and
meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE
(through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases
relevant to this guideline.
STRUCTURE Many recommendations from previously published guidelines have been updated with new evidence, and new rec-
ommendations have been created when supported by published data.
Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association
(professional.heart.org). For copies of this document, please contact the Elsevier Inc. Reprint Department, via fax (212-633-3820) or e-mail
().
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the
express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (https://www.elsevier.
com/about/policies-and-standards/copyright/permissions).
Descargado para Alejandro Ramírez Ramírez () en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en abril
11, 2025. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2025. Elsevier Inc. Todos los derechos reservados.
,JACC VOL. -, NO. -, 2025 Rao et al 3
-, 2025:-–- 2025 Acute Coronary Syndromes Management Guideline
TABLE OF CONTENTS
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 4.7. Renin-Angiotensin-Aldosterone
System Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 35
TOP TAKE-HOME MESSAGES . . . . . . . . . . . . . . . . . . . . . . . 4
5. STEMI MANAGEMENT: REPERFUSION
STRATEGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
PREAMBLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
5.1. Regional Systems of STEMI Care . . . . . . . . . . . . . . 36
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 5.2. Reperfusion at PCI-Capable Hospitals . . . . . . . . . . 38
1.1. Methodology and Evidence Review . . . . . . . . . . . . 6 5.2.1. PPCI in STEMI . . . . . . . . . . . . . . . . . . . . . . . . 38
5.2.2. Urgent CABG Surgery . . . . . . . . . . . . . . . . . . 39
1.2. Composition of the Writing Committee . . . . . . . . . 7
1.3. Guideline Review and Approval . . . . . . . . . . . . . . . 7 5.3. Reperfusion at Non–PCI-Capable Hospitals . . . . . . 40
5.3.1. Timing and Choice of Agent for
1.4. Scope of the Guideline . . . . . . . . . . . . . . . . . . . . . . . 7 Fibrinolytic Therapy . . . . . . . . . . . . . . . . . . . 41
1.5. Class of Recommendation and 5.3.2. Coronary Angiography and PCI After
Level of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Fibrinolytic Therapy . . . . . . . . . . . . . . . . . . . 42
1.6. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
6. NSTE-ACS: ROUTINE INVASIVE OR SELECTIVE
INVASIVE INITIAL APPROACH . . . . . . . . . . . . . . . . . 43
2. OVERVIEW OF ACS . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
6.1. Rationale and Timing for a Routine Invasive or
2.1. Definition and Classification of ACS . . . . . . . . . . . 10 Selective Invasive Approach . . . . . . . . . . . . . . . . . 43
3. INITIAL EVALUATION AND MANAGEMENT OF 7. CATHETERIZATION LABORATORY
SUSPECTED ACS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CONSIDERATIONS IN ACS . . . . . . . . . . . . . . . . . . . . . 46
3.1. Initial Assessment of Suspected ACS . . . . . . . . . . . 13 7.1. Vascular Access Approach for PCI . . . . . . . . . . . . . 46
3.1.1. Prehospital Assessment and Management
7.2. Use of Aspiration Thrombectomy . . . . . . . . . . . . . 47
Considerations for Suspected ACS . . . . . . . . 13
3.1.2. Initial In-Hospital Assessment of Patients 7.3. Use of Intracoronary Imaging . . . . . . . . . . . . . . . . 48
With Confirmed or Suspected ACS . . . . . . . 15
7.4. Management of Multivessel CAD in ACS . . . . . . . 49
3.1.3. Risk Stratification Tools for Patients With
7.4.1. Management of Multivessel CAD
STEMI and NSTE-ACS . . . . . . . . . . . . . . . . . . 17
in STEMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3.2. Management of Patients Presenting With 7.4.2. Management of Multivessel CAD
Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 in NSTE-ACS . . . . . . . . . . . . . . . . . . . . . . . . . 51
4. STANDARD MEDICAL THERAPIES FOR STEMI 8. CARDIOGENIC SHOCK MANAGEMENT . . . . . . . . . . . 52
AND NSTE-ACS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 8.1. Revascularization in ACS With Cardiogenic Shock . . 52
4.1. Oxygen Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 8.2. MCS in Patients With ACS and Cardiogenic Shock . 53
4.2. Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
9. ACS COMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . 55
4.3. Antiplatelet Therapy . . . . . . . . . . . . . . . . . . . . . . . 21
4.3.1. Aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 9.1. Mechanical Complications . . . . . . . . . . . . . . . . . . . 55
4.3.2. Oral P2Y12 Inhibitors 9.2. Electrical Complications and Prevention of
During Hospitalization . . . . . . . . . . . . . . . . . 22 Sudden Cardiac Death After ACS . . . . . . . . . . . . . 56
4.3.3. Intravenous P2Y12 Inhibition . . . . . . . . . . . 25 9.3. Pericarditis Management After MI . . . . . . . . . . . . 58
4.3.4. Intravenous Glycoprotein IIb/IIIa
9.4. Management of LV Thrombus After MI . . . . . . . . 58
Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.4. Parenteral Anticoagulation . . . . . . . . . . . . . . . . . . 27 10. IN-HOSPITAL ISSUES IN THE MANAGEMENT OF ACS . . 59
4.5. Lipid Management . . . . . . . . . . . . . . . . . . . . . . . . . 31 10.1. Cardiac Intensive Care Unit . . . . . . . . . . . . . . . . . 59
4.6. Beta-Blocker Therapy . . . . . . . . . . . . . . . . . . . . . . . 34 10.2. Management of Anemia in ACS . . . . . . . . . . . . . . 59
Descargado para Alejandro Ramírez Ramírez () en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en abril
11, 2025. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2025. Elsevier Inc. Todos los derechos reservados.
, 4 Rao et al JACC VOL. -, NO. -, 2025
2025 Acute Coronary Syndromes Management Guideline -, 2025:-–-
10.3. Telemetry and Length of Stay . . . . . . . . . . . . . . . 60 reduce bleeding risk in patients with ACS who have
undergone PCI and require antiplatelet therapy: (a) in
10.4. Noninvasive Diagnostic Testing Prior to
Hospital Discharge . . . . . . . . . . . . . . . . . . . . . . . . 61 patients at risk for gastrointestinal bleeding, a proton
pump inhibitor is recommended; (b) in patients who
10.5. Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . 61
have tolerated dual antiplatelet therapy with tica-
10.5.1. Patient Education . . . . . . . . . . . . . . . . . . . 61 grelor, transition to ticagrelor monotherapy is
10.5.2. Postdischarge Follow-Up and Systems of recommended $1 month after PCI; or (c) in patients
Care Coordination . . . . . . . . . . . . . . . . . . . 62 who require long-term anticoagulation, aspirin
10.5.3. Cardiac Rehabilitation . . . . . . . . . . . . . . . 63 discontinuation is recommended 1 to 4 weeks after PCI
with continued use of a P2Y12 inhibitor (preferably
11. DISCHARGE: LONG-TERM MANAGEMENT AND clopidogrel).
SECONDARY PREVENTION . . . . . . . . . . . . . . . . . . . . 64 3. High-intensity statin therapy is recommended for all
11.1. DAPT Strategies in the patients with ACS, and with the option to initiate con-
First 12 Months Postdischarge . . . . . . . . . . . . . . . 64 current ezetimibe. A nonstatin lipid-lowering agent (eg,
11.1.1. Antiplatelet Therapy in Patients on ezetimibe, evolocumab, alirocumab, inclisiran, bem-
Anticoagulation Postdischarge . . . . . . . . . 67 pedoic acid) is recommended for patients already on
maximally tolerated statin who have a low-density li-
11.2. Reassessment of Lipid Levels Postdischarge . . . . 68
poprotein cholesterol level of $70 mg/dL (1.8 mmol/L).
11.3. SGLT-2 Inhibitors and GLP-1 Receptor It is reasonable in this high-risk population to further
Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 intensify lipid-lowering therapy if the low-density
11.4. Use of Chronic Colchicine . . . . . . . . . . . . . . . . . . . 69 lipoprotein cholesterol level is 55 to <70 mg/dL
(1.4 to <1.8 mmol/L) and patient is already on a maxi-
11.5. Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
mally tolerated statin.
4. In patients with non–ST-segment elevation ACS who
12. EVIDENCE GAPS AND FUTURE DIRECTIONS . . . . . 70
are at intermediate or high risk of ischemic events, an
invasive approach with the intent to proceed with
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
revascularization is recommended during hospitaliza-
tion to reduce major adverse cardiovascular events. In
APPENDIX 1
patients with non–ST-segment elevation ACS who are
Author Relationships With Industry and at low risk of ischemic events, a routine invasive or
Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 selective invasive approach with further risk stratifi-
cation is recommended to help identify those who may
APPENDIX 2 require revascularization and to reduce major adverse
Reviewer Relationships With Industry and cardiovascular events.
Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 5. Two procedural strategies are recommended in pa-
tients with ACS who are undergoing PCI: (a) radial
TOP TAKE-HOME MESSAGES approach is preferred over femoral approach in pa-
tients with ACS undergoing PCI to reduce bleeding,
1. Dual antiplatelet therapy is recommended for patients vascular complications, and death; and (b) intra-
with acute coronary syndromes (ACS). Ticagrelor or coronary imaging is recommended to guide PCI in pa-
prasugrel is recommended in preference to clopidogrel tients with ACS with complex coronary lesions.
in patients with ACS who are undergoing percutaneous 6. A strategy of complete revascularization is recom-
coronary intervention (PCI). In patients with non–ST- mended in patients with ST-segment elevation
segment elevation ACS who are scheduled for an myocardial infarction or non–ST-segment elevation
invasive strategy with timing of angiography to be >24 ACS. The choice of revascularization method (ie, cor-
hours, upstream treatment with clopidogrel or tica- onary artery bypass graft surgery versus multivessel
grelor may be considered to reduce major adverse PCI) in non–ST-segment elevation ACS and multivessel
cardiovascular events. disease should be based on the complexity of the cor-
2. Dual antiplatelet therapy with aspirin and an oral onary artery disease and comorbid conditions. PCI of
P2Y12 inhibitor is indicated for at least 12 months as the significant nonculprit stenoses for patients with ST-
default strategy in patients with ACS who are not at segment elevation myocardial infarction can be per-
high bleeding risk. Several strategies are available to formed in a single procedure or staged with some
Descargado para Alejandro Ramírez Ramírez () en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en abril
11, 2025. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2025. Elsevier Inc. Todos los derechos reservados.
ª 2025 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION,
AND THE AMERICAN HEART ASSOCIATION, INC.
PUBLISHED BY ELSEVIER
CLINICAL PRACTICE GUIDELINE
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
Developed in Collaboration With and Endorsed by the American College of Emergency Physicians,
National Association of EMS Physicians, and Society for Cardiovascular Angiography
and Interventions
Writing Sunil V. Rao, MD, FACC, FSCAI, Chair Debabrata Mukherjee, MD, MS, FACC, FAHA, MSCAI
Committee Michelle L. O’Donoghue, MD, MPH, FACC, FAHA, Vice Chair Elke Platz, MD, MS, FACEP
Members* Marc Ruel, MD, MPH, FACC, FAHA, Vice Chair Susan B. Promes, MD, MBA, FACEPk
Tanveer Rab, MD, FACC, MSCAI, JC Liaisony Sigrid Sandner, MD, MS
Jaqueline E. Tamis-Holland, MD, FACC, FAHA, FSCAI, Yader Sandoval, MD, FACC, FSCAI
JC Liaisony Rachel Schunder, MA{
Binita Shah, MD, MS
John H. Alexander, MD, MHS, FACC, FAHA Jason P. Stopyra, MD, MS#
Usman Baber, MD, MS, FACC, FSCAI Amy W. Talbot, MPH{
Heather Baker, EDDz Pam R. Taub, MD, FACC
Mauricio G. Cohen, MD, FACC, FSCAI Marlene S. Williams, MD, FACC**
Mercedes Cruz-Ruiz, CHWIz
Leslie L. Davis, PHD, RN, ANP-BC, FACC, FAHA
James A. de Lemos, MD, FACC, FAHA *Writing committee members are required to recuse themselves from
voting on sections to which their specific relationships with industry may
Tracy A. DeWald, PHARMD, MHS, BCPS-AQ CARDIOLOGY
apply; see Appendix 1 for detailed information.
Islam Y. Elgendy, MD, FACC, FAHA, FSCAI yACC/AHA Joint Committee on Clinical Practice Guidelines liaison.
Dmitriy N. Feldman, MD, FACC, FSCAIx zLay stakeholder/patient representative.
Abhinav Goyal, MD, MHS, FACC, FAHA xSociety for Cardiovascular Angiography and Interventions representative.
kAmerican College of Emergency Physicians representative.
Ijeoma Isiadinso, MD, MPH, FACC
{ACC/AHA joint staff representative.
Venu Menon, MD, FACC, FAHA #National Association of EMS Physicians representative.
David A. Morrow, MD, MPH, FACC, FAHA **ACC/AHA Joint Committee on Performance Measures representative.
This document was approved by the American College of Cardiology Clinical Policy Approval Committee and the American Heart Association Science
Advisory and Coordinating Committee in October 2024, the American College of Cardiology Science and Quality Committee in October 2024, and the
American Heart Association Executive Committee in November 2024.
The American College of Cardiology requests that this document be cited as follows: Rao SV, O’Donoghue ML, Ruel M, Rab T, Tamis-Holland JE,
Alexander JH, Baber U, Baker H, Cohen MG, Cruz-Ruiz M, Davis LL, de Lemos JA, DeWald TA, Elgendy IY, Feldman DN, Goyal A, Isiadinso I, Menon V,
Morrow DA, Mukherjee D, Platz E, Promes SB, Sandner S, Sandoval Y, Schunder R, Shah B, Stopyra JP, Talbot AW, Taub PR, Williams MS. 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. JACC. Published online February 27, 2025. https://doi.org/10.1016/j.jacc.2024.11.009
This article has been copublished in Circulation.
ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2024.11.009
Descargado para Alejandro Ramírez Ramírez () en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en abril
11, 2025. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2025. Elsevier Inc. Todos los derechos reservados.
,2 Rao et al JACC VOL. -, NO. -, 2025
2025 Acute Coronary Syndromes Management Guideline -, 2025:-–-
Peer Review Hani Jneid, MD, FACC, FAHA, FSCAI, Chair Noreen T. Nazir, MD, FACC
Committee Derek So, MD, MSc, FACC
Members Craig J. Beavers, PharmD, FACC, FAHA Matthew Tomey, MD, FACC, FAHA, FSCAI
Theresa Beckie, PhD, RN, FAHA Frederick Welt, MD, FACCx
Jim Blankenship, MD, MACC
Deborah Diercks, MD, FACC jjAmerican College of Emergency Physicians representative.
xSociety for Cardiovascular Angiography and Interventions
Bruce Lo, MDjj
representative.
Clauden Louis, MD, FACC
Faisal M. Merchant, MD, FACC
ACC/AHA Joint Catherine M. Otto, MD, FACC, FAHA, Chair W. Schuyler Jones, MD, FACC
Committee On Sunil V. Rao, MD, FACC, FSCAI, Chair-Elect Sadiya S. Khan, MD, MSc, FACC, FAHA
Clinical Practice Joshua A. Beckman, MD, MS, FAHA, FACC, Prateeti Khazanie, MD, FAHAyy
Guidelines Immediate Past Chairyy Michelle M. Kittleson, MD, FACC, FAHA
Members Venu Menon, MD, FACC, FAHA
Anastasia Armbruster, PharmD, FACC Debabrata Mukherjee, MD, MS, FACC, FAHA, MSCAI
Vanessa Blumer, MD, FACC Latha Palaniappan, MD, MS, FACC, FAHAyy
Leslie L. Davis, PhD, RN, ANP-BC, FACC, FAHA Tanveer Rab, MD, FACC, MSCAIyy
Lisa de las Fuentes, MD, MS, FAHAyy Garima Sharma, MBBS, FACC, FAHA
Anita Deswal, MD, MPH, FACC, FAHAyy Daichi Shimbo, MD
Victor A. Ferrari, MD, FACC Jacqueline E. Tamis-Holland, MD, FACC, FAHA, FSCAIyy
Stephen E. Fremes, MD, FACC Y. Joseph Woo, MD, FACC, FAHAyy
Mario Gaudino, MD, FACC, FAHA Boback Ziaeian, MD, PhD, FACC, FAHA
Adrian F. Hernandez, MD, FAHAyy
Hani Jneid, MD, FACC, FAHA yyFormer ACC/AHA Joint Committee on Clinical Practice Guidelines
member; current member during this writing effort.
Heather M. Johnson, MD, MS, FACC, FAHA
ABSTRACT
AIM The “2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes” incor-
porates new evidence since the “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction” and the
corresponding “2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes” and
the “2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial
Infarction.” The “2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes”
and the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” retire and replace, respectively, the “2016 ACC/AHA
Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease.”
METHODS A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and
meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE
(through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases
relevant to this guideline.
STRUCTURE Many recommendations from previously published guidelines have been updated with new evidence, and new rec-
ommendations have been created when supported by published data.
Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association
(professional.heart.org). For copies of this document, please contact the Elsevier Inc. Reprint Department, via fax (212-633-3820) or e-mail
().
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the
express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (https://www.elsevier.
com/about/policies-and-standards/copyright/permissions).
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,JACC VOL. -, NO. -, 2025 Rao et al 3
-, 2025:-–- 2025 Acute Coronary Syndromes Management Guideline
TABLE OF CONTENTS
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 4.7. Renin-Angiotensin-Aldosterone
System Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 35
TOP TAKE-HOME MESSAGES . . . . . . . . . . . . . . . . . . . . . . . 4
5. STEMI MANAGEMENT: REPERFUSION
STRATEGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
PREAMBLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
5.1. Regional Systems of STEMI Care . . . . . . . . . . . . . . 36
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 5.2. Reperfusion at PCI-Capable Hospitals . . . . . . . . . . 38
1.1. Methodology and Evidence Review . . . . . . . . . . . . 6 5.2.1. PPCI in STEMI . . . . . . . . . . . . . . . . . . . . . . . . 38
5.2.2. Urgent CABG Surgery . . . . . . . . . . . . . . . . . . 39
1.2. Composition of the Writing Committee . . . . . . . . . 7
1.3. Guideline Review and Approval . . . . . . . . . . . . . . . 7 5.3. Reperfusion at Non–PCI-Capable Hospitals . . . . . . 40
5.3.1. Timing and Choice of Agent for
1.4. Scope of the Guideline . . . . . . . . . . . . . . . . . . . . . . . 7 Fibrinolytic Therapy . . . . . . . . . . . . . . . . . . . 41
1.5. Class of Recommendation and 5.3.2. Coronary Angiography and PCI After
Level of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Fibrinolytic Therapy . . . . . . . . . . . . . . . . . . . 42
1.6. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
6. NSTE-ACS: ROUTINE INVASIVE OR SELECTIVE
INVASIVE INITIAL APPROACH . . . . . . . . . . . . . . . . . 43
2. OVERVIEW OF ACS . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
6.1. Rationale and Timing for a Routine Invasive or
2.1. Definition and Classification of ACS . . . . . . . . . . . 10 Selective Invasive Approach . . . . . . . . . . . . . . . . . 43
3. INITIAL EVALUATION AND MANAGEMENT OF 7. CATHETERIZATION LABORATORY
SUSPECTED ACS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CONSIDERATIONS IN ACS . . . . . . . . . . . . . . . . . . . . . 46
3.1. Initial Assessment of Suspected ACS . . . . . . . . . . . 13 7.1. Vascular Access Approach for PCI . . . . . . . . . . . . . 46
3.1.1. Prehospital Assessment and Management
7.2. Use of Aspiration Thrombectomy . . . . . . . . . . . . . 47
Considerations for Suspected ACS . . . . . . . . 13
3.1.2. Initial In-Hospital Assessment of Patients 7.3. Use of Intracoronary Imaging . . . . . . . . . . . . . . . . 48
With Confirmed or Suspected ACS . . . . . . . 15
7.4. Management of Multivessel CAD in ACS . . . . . . . 49
3.1.3. Risk Stratification Tools for Patients With
7.4.1. Management of Multivessel CAD
STEMI and NSTE-ACS . . . . . . . . . . . . . . . . . . 17
in STEMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3.2. Management of Patients Presenting With 7.4.2. Management of Multivessel CAD
Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 in NSTE-ACS . . . . . . . . . . . . . . . . . . . . . . . . . 51
4. STANDARD MEDICAL THERAPIES FOR STEMI 8. CARDIOGENIC SHOCK MANAGEMENT . . . . . . . . . . . 52
AND NSTE-ACS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 8.1. Revascularization in ACS With Cardiogenic Shock . . 52
4.1. Oxygen Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 8.2. MCS in Patients With ACS and Cardiogenic Shock . 53
4.2. Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
9. ACS COMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . 55
4.3. Antiplatelet Therapy . . . . . . . . . . . . . . . . . . . . . . . 21
4.3.1. Aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 9.1. Mechanical Complications . . . . . . . . . . . . . . . . . . . 55
4.3.2. Oral P2Y12 Inhibitors 9.2. Electrical Complications and Prevention of
During Hospitalization . . . . . . . . . . . . . . . . . 22 Sudden Cardiac Death After ACS . . . . . . . . . . . . . 56
4.3.3. Intravenous P2Y12 Inhibition . . . . . . . . . . . 25 9.3. Pericarditis Management After MI . . . . . . . . . . . . 58
4.3.4. Intravenous Glycoprotein IIb/IIIa
9.4. Management of LV Thrombus After MI . . . . . . . . 58
Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.4. Parenteral Anticoagulation . . . . . . . . . . . . . . . . . . 27 10. IN-HOSPITAL ISSUES IN THE MANAGEMENT OF ACS . . 59
4.5. Lipid Management . . . . . . . . . . . . . . . . . . . . . . . . . 31 10.1. Cardiac Intensive Care Unit . . . . . . . . . . . . . . . . . 59
4.6. Beta-Blocker Therapy . . . . . . . . . . . . . . . . . . . . . . . 34 10.2. Management of Anemia in ACS . . . . . . . . . . . . . . 59
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, 4 Rao et al JACC VOL. -, NO. -, 2025
2025 Acute Coronary Syndromes Management Guideline -, 2025:-–-
10.3. Telemetry and Length of Stay . . . . . . . . . . . . . . . 60 reduce bleeding risk in patients with ACS who have
undergone PCI and require antiplatelet therapy: (a) in
10.4. Noninvasive Diagnostic Testing Prior to
Hospital Discharge . . . . . . . . . . . . . . . . . . . . . . . . 61 patients at risk for gastrointestinal bleeding, a proton
pump inhibitor is recommended; (b) in patients who
10.5. Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . 61
have tolerated dual antiplatelet therapy with tica-
10.5.1. Patient Education . . . . . . . . . . . . . . . . . . . 61 grelor, transition to ticagrelor monotherapy is
10.5.2. Postdischarge Follow-Up and Systems of recommended $1 month after PCI; or (c) in patients
Care Coordination . . . . . . . . . . . . . . . . . . . 62 who require long-term anticoagulation, aspirin
10.5.3. Cardiac Rehabilitation . . . . . . . . . . . . . . . 63 discontinuation is recommended 1 to 4 weeks after PCI
with continued use of a P2Y12 inhibitor (preferably
11. DISCHARGE: LONG-TERM MANAGEMENT AND clopidogrel).
SECONDARY PREVENTION . . . . . . . . . . . . . . . . . . . . 64 3. High-intensity statin therapy is recommended for all
11.1. DAPT Strategies in the patients with ACS, and with the option to initiate con-
First 12 Months Postdischarge . . . . . . . . . . . . . . . 64 current ezetimibe. A nonstatin lipid-lowering agent (eg,
11.1.1. Antiplatelet Therapy in Patients on ezetimibe, evolocumab, alirocumab, inclisiran, bem-
Anticoagulation Postdischarge . . . . . . . . . 67 pedoic acid) is recommended for patients already on
maximally tolerated statin who have a low-density li-
11.2. Reassessment of Lipid Levels Postdischarge . . . . 68
poprotein cholesterol level of $70 mg/dL (1.8 mmol/L).
11.3. SGLT-2 Inhibitors and GLP-1 Receptor It is reasonable in this high-risk population to further
Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 intensify lipid-lowering therapy if the low-density
11.4. Use of Chronic Colchicine . . . . . . . . . . . . . . . . . . . 69 lipoprotein cholesterol level is 55 to <70 mg/dL
(1.4 to <1.8 mmol/L) and patient is already on a maxi-
11.5. Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
mally tolerated statin.
4. In patients with non–ST-segment elevation ACS who
12. EVIDENCE GAPS AND FUTURE DIRECTIONS . . . . . 70
are at intermediate or high risk of ischemic events, an
invasive approach with the intent to proceed with
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
revascularization is recommended during hospitaliza-
tion to reduce major adverse cardiovascular events. In
APPENDIX 1
patients with non–ST-segment elevation ACS who are
Author Relationships With Industry and at low risk of ischemic events, a routine invasive or
Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 selective invasive approach with further risk stratifi-
cation is recommended to help identify those who may
APPENDIX 2 require revascularization and to reduce major adverse
Reviewer Relationships With Industry and cardiovascular events.
Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 5. Two procedural strategies are recommended in pa-
tients with ACS who are undergoing PCI: (a) radial
TOP TAKE-HOME MESSAGES approach is preferred over femoral approach in pa-
tients with ACS undergoing PCI to reduce bleeding,
1. Dual antiplatelet therapy is recommended for patients vascular complications, and death; and (b) intra-
with acute coronary syndromes (ACS). Ticagrelor or coronary imaging is recommended to guide PCI in pa-
prasugrel is recommended in preference to clopidogrel tients with ACS with complex coronary lesions.
in patients with ACS who are undergoing percutaneous 6. A strategy of complete revascularization is recom-
coronary intervention (PCI). In patients with non–ST- mended in patients with ST-segment elevation
segment elevation ACS who are scheduled for an myocardial infarction or non–ST-segment elevation
invasive strategy with timing of angiography to be >24 ACS. The choice of revascularization method (ie, cor-
hours, upstream treatment with clopidogrel or tica- onary artery bypass graft surgery versus multivessel
grelor may be considered to reduce major adverse PCI) in non–ST-segment elevation ACS and multivessel
cardiovascular events. disease should be based on the complexity of the cor-
2. Dual antiplatelet therapy with aspirin and an oral onary artery disease and comorbid conditions. PCI of
P2Y12 inhibitor is indicated for at least 12 months as the significant nonculprit stenoses for patients with ST-
default strategy in patients with ACS who are not at segment elevation myocardial infarction can be per-
high bleeding risk. Several strategies are available to formed in a single procedure or staged with some
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