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Treat: 2025 ACC/AHA ACS guideline

Every recommendation from the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes, with its class, level of evidence, supportive text, and references.

This guideline predates the 5th UDMI and uses 4th UDMI terms, for example type 1 and type 2 MI. Its recommendations are for type 1 MI, which corresponds to primary MI due to atherothrombosis.

Open the 4th → 5th UDMI crosswalk

Recommendations, supportive text, and references are reproduced verbatim from . Each reference is a tag: click it for the full citation and a link to the paper. Section numbers match the guideline. Class: I (green) is recommended, IIa (yellow) is reasonable, IIb (orange) may be considered, III (red) is no benefit or harm.

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103 of 103 recommendations

3.1.1Prehospital Assessment and Management Considerations for Suspected ACS

Suspected ACS

In patients with suspected ACS, a 12-lead ECG should be acquired and interpreted within 10 minutes of first medical contact (FMC)* to identify patients with STEMI.

  • *FMC indicates the time point when the patient is initially assessed by a health care professional who can obtain and interpret the ECG and deliver initial interventions (eg, defibrillation).
Class ILOE B-NR§3.1.1 · Rec 1

Suspected ACS

In patients with suspected ACS in which the initial ECG is nondiagnostic of STEMI, serial ECGs to detect potential ischemic changes should be performed, especially when clinical suspicion of ACS is high, symptoms are persistent, or the clinical condition deteriorates.†

  • †Modified from the “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.”
Class ILOE C-LD§3.1.1 · Rec 2

STEMI

In patients with suspected STEMI, immediate emergency medical services (EMS) transport to a PCI-capable hospital for primary PCI (PPCI‡) is the recommended triage strategy, with an FMC–to-first-device time system goal of ≤90 minutes.

  • ‡PPCI refers to emergency PCI in the setting of STEMI to achieve reperfusion in patients without previous fibrinolytic treatment.
Class ILOE B-NR§3.1.1 · Rec 3

STEMI

In patients with suspected STEMI, early advance notification of the receiving PCI-capable hospital by EMS personnel and activation of the cardiac catheterization team is recommended to reduce time to reperfusion.

Class ILOE B-NR§3.1.1 · Rec 4

3.1.2Initial In-Hospital Assessment of Patients With Confirmed or Suspected ACS

In patients with suspected ACS, acquisition and interpretation of an ECG within 10 minutes is recommended to help guide patient management.*

  • *Adapted from the “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.”
Class ILOE B-NR§3.1.2 · Rec 1

In patients with suspected ACS in whom the initial ECG is nondiagnostic, serial 12-lead ECGs should be performed to detect potential ischemic changes, especially when clinical suspicion of ACS is high, symptoms are persistent, or clinical condition deteriorates.*

  • *Adapted from the “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.”
Class ILOE B-NR§3.1.2 · Rec 2

In patients with suspected ACS, cTn should be measured as soon as possible, preferably using a high-sensitivity cTn (hs-cTn) assay.*

  • *Adapted from the “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.”
Class ILOE B-NR§3.1.2 · Rec 3

In patients with suspected ACS with an initial hs-cTn or cTn that is nondiagnostic, the recommended time intervals for repeat measurements after the initial sample collection (time zero) are 1 to 2 hours for hs-cTn and 3 to 6 hours for conventional cTn assays.*

  • *Adapted from the “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.”
Class ILOE B-NR§3.1.2 · Rec 4

3.2Management of Patients Presenting With Cardiac Arrest

Patients with cardiac arrest and STEMI who have been resuscitated should preferentially be transferred by EMS to a PPCI-capable center.

Class ILOE C-LD§3.2 · Rec 1

Patients who have been resuscitated after cardiac arrest and are noncomatose or who are comatose with favorable prognostic features and with evidence of STEMI, should undergo PPCI to improve survival.

Class ILOE B-NR§3.2 · Rec 2

In patients with cardiac arrest who are comatose, have unfavorable prognostic features, and evidence of STEMI, PPCI may be reasonable after individualized assessment.

Class IIbLOE C-LD§3.2 · Rec 3

In resuscitated patients who are comatose after cardiac arrest, electrically and hemodynamically stable, and without evidence of STEMI, immediate angiography is not recommended due to lack of benefit.

Class III: No BenefitLOE A§3.2 · Rec 4

4.1Oxygen Therapy

In patients with ACS and confirmed hypoxia (oxygen saturation <90%), supplemental oxygen to increase oxygen saturations to ≥90% is recommended to improve myocardial oxygen supply and decrease anginal symptoms.

Class ILOE C-LD§4.1 · Rec 1

In patients with ACS and oxygen saturations ≥90%, routine administration of supplemental oxygen is not recommended because it does not improve cardiovascular outcomes.

Class III: No BenefitLOE A§4.1 · Rec 2

4.3.1Aspirin

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

Class ILOE A§4.3.1 · Rec 1

4.3.2Oral P2Y12 Inhibitors During Hospitalization

All Patients With ACS (STEMI and NSTE-ACS)

In patients with ACS, an oral P2Y12 inhibitor should be administered in addition to aspirin to reduce MACE.

Class ILOE A§4.3.2 · Rec 1

All Patients With ACS (STEMI and NSTE-ACS)

In patients with a history of stroke or transient ischemic attack, prasugrel should not be administered because of worse net clinical outcomes.*†

  • *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” and the †”2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease.”
Class III: HarmLOE B-R§4.3.2 · Rec 2

In-Hospital Management in Patients With NSTE-ACS

In patients with NSTE-ACS undergoing PCI, prasugrel or ticagrelor is recommended to reduce MACE and stent thrombosis.

Class ILOE B-R§4.3.2 · Rec 3

In-Hospital Management in Patients With NSTE-ACS

In patients with NSTE-ACS who are managed without planned invasive evaluation, ticagrelor is recommended to reduce MACE.

Class ILOE B-R§4.3.2 · Rec 4

In-Hospital Management in Patients With NSTE-ACS

In patients with NSTE-ACS, clopidogrel is recommended to reduce MACE when prasugrel or ticagrelor are unavailable, cannot be tolerated, or are contraindicated.

Class ILOE B-R§4.3.2 · Rec 5

In-Hospital Management in Patients With NSTE-ACS

In patients with NSTE-ACS planned for an invasive strategy with timing of angiography anticipated to be >24 hours, upstream treatment with clopidogrel or ticagrelor may be considered to reduce MACE.

Class IIbLOE B-NR§4.3.2 · Rec 6

In-Hospital Management in Patients With STEMI

In patients with STEMI managed with PPCI, prasugrel or ticagrelor should be administered to reduce MACE and stent thrombosis.

Class ILOE B-R§4.3.2 · Rec 7

In-Hospital Management in Patients With STEMI

In patients with STEMI managed with PPCI, clopidogrel is recommended to reduce MACE and stent thrombosis when prasugrel or ticagrelor are unavailable, cannot be tolerated, or are contraindicated.

Class ILOE C-LD§4.3.2 · Rec 8

In-Hospital Management in Patients With STEMI

In patients with STEMI managed with fibrinolytic therapy, clopidogrel should be administered concurrently to reduce death and MACE.

Class ILOE A§4.3.2 · Rec 9

4.3.3Intravenous P2Y12 Inhibition

Among patients with ACS undergoing PCI who have not received a P2Y12 inhibitor, intravenous cangrelor may be reasonable to reduce periprocedural ischemic events.*

  • *Reproduced from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class IIbLOE B-R§4.3.3 · Rec 1

4.3.4Intravenous Glycoprotein IIb/IIIa Inhibitors

In patients with ACS undergoing PCI with large thrombus burden, no-reflow, or slow flow, adjunctive use of an intravenous or intracoronary glycoprotein IIb/IIIa inhibitor is reasonable to improve procedural success and reduce infarct size.*

  • *Adapted from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class IIaLOE C-LD§4.3.4 · Rec 1

In patients with ACS, glycoprotein IIb/IIIa inhibitors should not be administered routinely due to lack of ischemic benefit and increased risk of bleeding.

Class III: HarmLOE B-R§4.3.4 · Rec 2

4.4Parenteral Anticoagulation

NSTE-ACS: Upstream* Anticoagulant Therapy

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

  • *At the time of diagnosis and prior to invasive coronary angiography if planned.
  • †Adapted or ‡modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE B-R§4.4 · Rec 1

NSTE-ACS: Upstream* Anticoagulant Therapy

In patients with NSTE-ACS in whom an early invasive approach is not anticipated, either enoxaparin or fondaparinux are recommended alternatives to UFH to reduce ischemic events.

  • *At the time of diagnosis and prior to invasive coronary angiography if planned.
Class ILOE B-R§4.4 · Rec 2

Anticoagulant Therapy in Patients Undergoing Coronary Revascularization

In patients with ACS undergoing coronary revascularization (CABG or PCI) in the same admission, parenteral anticoagulation should be continued until revascularization to reduce ischemic events.

Class ILOE C-LD§4.4 · Rec 3

Anticoagulant Therapy to Support PCI in ACS (STEMI and NSTE-ACS)

In patients with ACS undergoing PCI, intravenous UFH is useful to reduce ischemic events.†

  • †Adapted or ‡modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE C-EO§4.4 · Rec 4

Anticoagulant Therapy to Support PCI in ACS (STEMI and NSTE-ACS)

In patients with STEMI undergoing PCI, bivalirudin is useful as an alternative to UFH to reduce mortality and bleeding.†

  • †Adapted or ‡modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE B-R§4.4 · Rec 5

Anticoagulant Therapy to Support PCI in ACS (STEMI and NSTE-ACS)

In patients with NSTE-ACS undergoing PCI, bivalirudin may be reasonable as an alternative to UFH to reduce bleeding.†

  • †Adapted or ‡modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class IIbLOE B-R§4.4 · Rec 6

Anticoagulant Therapy to Support PCI in ACS (STEMI and NSTE-ACS)

In patients with ACS, intravenous enoxaparin may be considered as an alternative to UFH at the time of PCI to reduce ischemic events.‡

  • †Adapted or ‡modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class IIbLOE B-R§4.4 · Rec 7

Anticoagulant Therapy to Support PCI in ACS (STEMI and NSTE-ACS)

In patients with ACS, fondaparinux should not be used to support PCI because of the risk of catheter thrombosis.

Class III: HarmLOE B-R§4.4 · Rec 8

STEMI: Anticoagulant Therapy Treated With Fibrinolytic Therapy

In patients with STEMI treated with fibrinolytic therapy, parenteral anticoagulation should be continued for the duration of the hospital stay (maximum of 8 days) or until revascularization is performed to reduce ischemic events.

Class ILOE A§4.4 · Rec 9

STEMI: Anticoagulant Therapy Treated With Fibrinolytic Therapy

In patients with STEMI treated with fibrinolytic therapy who are not intended to undergo an invasive approach, enoxaparin is the recommended anticoagulant to reduce ischemic events.

Class ILOE A§4.4 · Rec 10

STEMI: Anticoagulant Therapy Treated With Fibrinolytic Therapy

In patients with STEMI treated with fibrinolytic therapy who are not intended to undergo an invasive approach, fondaparinux is a recommended alternative to reduce ischemic events.

Class ILOE B-R§4.4 · Rec 11

4.5Lipid Management

In patients with ACS, high-intensity statin therapy is recommended to reduce the risk of MACE.*

  • *Modified or †adapted from the “2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease.”
Class ILOE A§4.5 · Rec 1

In patients with ACS who are already on maximally tolerated statin therapy with low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dL (≥1.8 mmol/L), adding a nonstatin lipid-lowering agent is recommended to further reduce the risk of MACE.†

  • *Modified or †adapted from the “2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease.”
Class ILOE A§4.5 · Rec 2

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

Class ILOE B-R§4.5 · Rec 3

In patients with ACS who are already on maximally tolerated statin therapy with LDL-C 55 to 69 mg/dL (≥1.4 to <1.8 mmol/L), adding a nonstatin lipid-lowering agent is reasonable to reduce the risk of MACE.*

  • *Modified or †adapted from the “2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease.”
Class IIaLOE B-R§4.5 · Rec 4

In patients with ACS, the concurrent initiation of ezetimibe in combination with maximally tolerated statin may be considered to reduce the risk of MACE.

Class IIbLOE B-R§4.5 · Rec 5

4.6Beta-Blocker Therapy

In patients with ACS without contraindications, early (<24 hours) initiation of oral beta-blocker therapy is recommended to reduce risk of reinfarction and ventricular arrhythmias.

Class ILOE A§4.6 · Rec 1

4.7Renin-Angiotensin-Aldosterone System Inhibitors

In high-risk patients with ACS (LVEF ≤40%, hypertension, diabetes mellitus, or STEMI with anterior location), an oral angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) is indicated to reduce all-cause death and MACE.

Class ILOE A§4.7 · Rec 1

In patients with ACS and LVEF ≤40%, and with HF symptoms and/or diabetes mellitus, a mineralocorticoid receptor antagonist is indicated to reduce all-cause death and MACE.

Class ILOE B-R§4.7 · Rec 2

In patients with ACS who are not considered high risk, an oral ACEi or an ARB is reasonable to reduce MACE.

Class IIaLOE A§4.7 · Rec 3

5.1Regional Systems of STEMI Care

All communities should create and maintain regional systems of STEMI care that coordinate prehospital and hospital-based STEMI care processes with the goal of reducing total ischemic time and improving survival in patients with STEMI.

Class ILOE B-NR§5.1 · Rec 1

5.2.1PPCI in STEMI

In patients with STEMI presenting <12 hours after symptom onset, PPCI should be performed with a goal of FMC to device activation of ≤90 minutes, or ≤120 minutes in patients requiring hospital transfer, to improve survival.

Class ILOE A§5.2.1 · Rec 1

In patients with ACS and cardiogenic shock or hemodynamic instability, emergency revascularization of the culprit vessel by PCI or CABG is indicated to improve survival, irrespective of time from symptom onset.

Class ILOE B-R§5.2.1 · Rec 2

In patients with STEMI presenting 12 to 24 hours after symptom onset, PPCI is reasonable to improve clinical outcomes.*

  • *Reproduced or †modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class IIaLOE B-NR§5.2.1 · Rec 3

In patients with STEMI presenting >24 hours after symptom onset with the presence of ongoing ischemia or life-threatening arrhythmia, PPCI is reasonable to improve clinical outcomes.†

  • *Reproduced or †modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class IIaLOE C-LD§5.2.1 · Rec 4

In patients who are stable with STEMI who have a totally occluded infarct-related artery >24 hours after symptom onset and are without evidence of ongoing ischemia, acute severe HF, or life-threatening arrhythmia, PPCI should not be performed due to lack of benefit.†

  • *Reproduced or †modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class III: No BenefitLOE B-R§5.2.1 · Rec 5

5.2.2Urgent CABG Surgery

In patients with STEMI in whom PCI is not feasible or successful, with a large area of myocardium at risk, emergency or urgent CABG surgery can be effective to improve clinical outcomes.*

  • *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class IIaLOE B-NR§5.2.2 · Rec 1

5.3Reperfusion at Non–PCI-Capable Hospitals

In patients with STEMI and an estimated time from FMC to device activation of ≤120 minutes or those with a contraindication to fibrinolytic therapy, transfer to a PCI-capable hospital for PPCI is recommended to reduce MACE.

Class ILOE A§5.3 · Rec 1

In patients with STEMI and symptom onset of <12 hours and anticipated delay to PPCI >120 minutes from FMC, fibrinolytic therapy should be administered in patients without contraindication to reduce MACE.

Class ILOE A§5.3 · Rec 2

In patients with STEMI and symptom onset of 12 to 24 hours, transfer to a PCI-capable hospital for PPCI is reasonable to reduce infarct size and MACE.

Class IIaLOE B-NR§5.3 · Rec 3

In patients with only ST-segment depression, except when true posterior STEMI is suspected, fibrinolytic therapy should not be administered due to risk of hemorrhagic stroke and major noncerebral bleeding.

Class III: HarmLOE B-R§5.3 · Rec 4

5.3.2Coronary Angiography and PCI After Fibrinolytic Therapy

In patients with STEMI, transfer to a PCI-capable center immediately after fibrinolytic therapy is recommended.

Class ILOE A§5.3.2 · Rec 1

In patients with STEMI with suspected failed reperfusion after fibrinolytic therapy, immediate angiography with rescue PCI is recommended to reduce the risk of death or recurrent MI.*

  • *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE B-R§5.3.2 · Rec 2

In patients with STEMI treated with fibrinolytic therapy, early angiography between 2 and 24 hours with the intent to perform PCI is recommended to reduce the rates of death or MI.*

  • *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE B-R§5.3.2 · Rec 3

6.1Rationale and Timing for a Routine Invasive or Selective Invasive Approach

Routine Invasive Versus Selective Invasive Strategy

In patients with NSTE-ACS who are at intermediate or high risk of ischemic events and are appropriate candidates for revascularization, an invasive approach with the intent to proceed with revascularization is recommended during hospitalization to reduce MACE.*

  • *Reproduced or †modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE A§6.1 · Rec 1

Routine Invasive Versus Selective Invasive Strategy

In patients with NSTE-ACS who are at low risk of ischemic events, either a routine invasive or selective invasive approach is recommended to help identify those who may require revascularization and to reduce MACE.

Class ILOE A§6.1 · Rec 2

Timing of Coronary Angiography for Those in Whom an Invasive Approach Is Planned

In patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability, an immediate invasive strategy with intent to perform revascularization is indicated to reduce MACE.†

  • *Reproduced or †modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE C-LD§6.1 · Rec 3

Timing of Coronary Angiography for Those in Whom an Invasive Approach Is Planned

In patients with NSTE-ACS who are at high risk‡ of ischemic events, it is reasonable to choose an early invasive strategy (within 24 hours) to reduce MACE.†

  • *Reproduced or †modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
  • ‡Predictors of risk are outlined in Figure 8.
Class IIaLOE B-R§6.1 · Rec 4

Timing of Coronary Angiography for Those in Whom an Invasive Approach Is Planned

In patients with NSTE-ACS who are not at high risk and are intended for an invasive strategy, it is reasonable to perform angiography before hospital discharge to reduce MACE.*

  • *Reproduced or †modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class IIaLOE B-R§6.1 · Rec 5

7.1Vascular Access Approach for PCI

In patients with ACS undergoing PCI, a radial approach is preferred to a femoral approach to reduce bleeding, vascular complications, and death.*

  • *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE A§7.1 · Rec 1

7.2Use of Aspiration Thrombectomy

Among patients with STEMI undergoing PPCI, manual aspiration thrombectomy should not be performed routinely prior to PCI given lack of clinical benefit.*

  • *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class III: No BenefitLOE A§7.2 · Rec 1

7.3Use of Intracoronary Imaging

In patients with ACS undergoing coronary stent implantation in left main artery or in complex lesions, intracoronary imaging with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) is recommended for procedural guidance to reduce ischemic events.*

  • *Adapted from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE A§7.3 · Rec 1

7.4.1Management of Multivessel CAD in STEMI

In selected, hemodynamically stable patients with STEMI and multivessel disease (MVD), after successful PCI of the infarct-related artery, PCI of significantly stenosed* noninfarct-related arteries is recommended to reduce the risk of death or MI and improve angina-related quality of life (QOL).†

  • *Significantly stenosed refers to lesions that are severely diseased as defined by the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” as a visually estimated diameter stenosis severity of 70% for non–left main disease and 50% for left main disease.
  • †Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE A§7.4.1 · Rec 1

In appropriate patients with STEMI and complex MVD, after successful PCI of the infarct-related artery, elective CABG surgery for significantly stenosed noninfarct-related arteries involving the left anterior descending artery or left main disease is reasonable to reduce the risk of cardiovascular events.†

  • †Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class IIaLOE C-EO§7.4.1 · Rec 2

In selected hemodynamically stable patients with STEMI and low-complexity MVD (those not intended for CABG surgery), multivessel PCI of significantly stenosed noninfarct-related arteries at the time of PPCI may be preferred over a staged approach to reduce the risk of cardiovascular events.

Class IIbLOE B-R§7.4.1 · Rec 3

In patients with STEMI complicated by cardiogenic shock, routine PCI of a noninfarct-related artery at the time of PPCI should not be performed because of the higher risk of death or renal failure.*

  • *Significantly stenosed refers to lesions that are severely diseased as defined by the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” as a visually estimated diameter stenosis severity of 70% for non–left main disease and 50% for left main disease.
Class III: HarmLOE B-R§7.4.1 · Rec 4

7.4.2Management of Multivessel CAD in NSTE-ACS

In patients with NSTE-ACS with MVD, the mode of revascularization (CABG or multivessel PCI) should be based on the disease complexity and patient’s comorbidities.

Class ILOE C-EO§7.4.2 · Rec 1

Multivessel CAD and Candidates for PCI

In stable patients with NSTE-ACS with MVD but without left main stenosis who are not intended for CABG surgery and undergoing culprit-lesion PCI, PCI of significant nonculprit lesions (at the time of the index procedure or as a staged procedure) is recommended to reduce the risk of MACE.

Class ILOE B-R§7.4.2 · Rec 2

Multivessel CAD and Candidates for PCI

In patients with NSTE-ACS in whom multivessel PCI is being considered, physiological assessment of a nonculprit stenosis may be considered to guide revascularization decisions.

Class IIbLOE B-R§7.4.2 · Rec 3

Multivessel CAD and Candidates for PCI

In patients with NSTE-ACS complicated by cardiogenic shock, routine PCI of a nonculprit artery at the time of index procedure should not be performed because of the higher risk of death or kidney failure.*

  • *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class III: HarmLOE B-R§7.4.2 · Rec 4

8.1Revascularization in ACS With Cardiogenic Shock

In patients with ACS and cardiogenic shock or hemodynamic instability, emergency revascularization of the culprit vessel by PCI or with CABG is indicated to improve survival, irrespective of time from symptom onset.

Class ILOE B-R§8.1 · Rec 1

In patients with ACS complicated by cardiogenic shock, routine PCI of a noninfarct-related artery at the time of PPCI should not be performed because of the higher risk of death or renal failure.*

  • *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class III: HarmLOE B-R§8.1 · Rec 2

8.2MCS in Patients With ACS and Cardiogenic Shock

In selected* patients with STEMI and severe or refractory cardiogenic shock, insertion of a microaxial intravascular flow pump is reasonable to reduce death.

  • *See supportive text.
Class IIaLOE B-R§8.2 · Rec 1

In patients with mechanical complication of ACS, short-term MCS devices are reasonable for hemodynamic stabilization as a bridge to surgery.

Class IIaLOE B-NR§8.2 · Rec 2

In patients with AMI and cardiogenic shock, the routine use of intra-aortic balloon pump (IABP) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) is not recommended due to a lack of survival benefit.

Class III: No BenefitLOE B-R§8.2 · Rec 3

9.1Mechanical Complications

Patients with a mechanical complication of ACS should be managed in a facility with cardiac surgical expertise.

Class ILOE C-EO§9.1 · Rec 1

In patients with a mechanical complication of ACS, short-term MCS devices are reasonable for hemodynamic stabilization as a bridge to surgery.

Class IIaLOE B-NR§9.1 · Rec 2

9.2Electrical Complications and Prevention of Sudden Cardiac Death After ACS

Ventricular Arrhythmias

In patients post MI, implantable cardioverter-defibrillator (ICD) implantation is recommended in selected patients with an LVEF ≤40% (Table 17) at least 40 days post MI and at least 90 days postrevascularization to reduce death.*

  • *Adapted from the “2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.”
Class ILOE A§9.2 · Rec 1

Ventricular Arrhythmias

In patients post ACS, ICD implantation is reasonable in patients with clinically relevant ventricular arrhythmias >48 hours and within 40 days post MI to improve survival.*

  • *Adapted from the “2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.”
Class IIaLOE C-EO§9.2 · Rec 2

Ventricular Arrhythmias

In patients early after MI, usefulness of a temporary wearable cardioverter-defibrillator is uncertain in patients with an LVEF ≤35% to improve survival.

Class IIbLOE B-R§9.2 · Rec 3

Bradyarrhythmias

In patients presenting with an AMI with sustained evidence of second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, alternating bundle-branch block, or third-degree atrioventricular block (persistent or infranodal), permanent pacing is indicated.†

  • †Adapted from the “2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay.”
Class ILOE B-NR§9.2 · Rec 4

10.1Cardiac Intensive Care Unit

Patients with ACS and with ongoing angina, hemodynamic instability, uncontrolled arrhythmias, suboptimal reperfusion, or cardiogenic shock should be admitted to a CICU to reduce cardiovascular events.

Class ILOE C-EO§10.1 · Rec 1

10.2Management of Anemia in ACS

In patients with ACS and acute or chronic anemia, blood transfusion to achieve a hemoglobin level ≥10 g/dL may be reasonable to reduce cardiovascular events.

Class IIbLOE B-R§10.2 · Rec 1

10.3Telemetry and Length of Stay

In patients with ACS, telemetry monitoring is recommended to reduce cardiovascular events with duration determined by cardiac risk.

Class ILOE C-LD§10.3 · Rec 1

10.4Noninvasive Diagnostic Testing Prior to Hospital Discharge

In patients with ACS, an assessment of LVEF is recommended prior to hospital discharge to guide therapy and for risk stratification.

Class ILOE C-LD§10.4 · Rec 1

10.5.3Cardiac Rehabilitation

Patients with ACS should be referred to an outpatient CR program prior to hospital discharge to reduce death, MI, hospital readmissions, and improve functional status and QOL.

Class ILOE A§10.5.3 · Rec 1

In patients with ACS, a home-based CR program is a reasonable alternative to a center-based CR program to improve functional status and QOL.

Class IIaLOE B-R§10.5.3 · Rec 2

11.1DAPT Strategies in the First 12 Months Postdischarge

Default Duration of DAPT

In patients with ACS who are not at high bleeding risk, DAPT with aspirin and an oral P2Y12 inhibitor should be administered for at least 1 year to reduce MACE.

Class ILOE A§11.1 · Rec 1

Bleeding Reduction Strategies

In patients with ACS who have tolerated DAPT with ticagrelor, transition to ticagrelor monotherapy ≥1 month post PCI is useful to reduce bleeding risk.

Class ILOE A§11.1 · Rec 2

Bleeding Reduction Strategies

In patients at high risk of gastrointestinal bleeding, a proton pump inhibitor (PPI) is recommended in combination with DAPT, oral anticoagulants, or both to reduce risk of bleeding.

Class ILOE A§11.1 · Rec 3

Bleeding Reduction Strategies

In patients with ACS undergoing PCI, de-escalation of DAPT (switching from ticagrelor or prasugrel to clopidogrel) after 1 month may be reasonable to reduce bleeding risk.

Class IIbLOE B-R§11.1 · Rec 4

Bleeding Reduction Strategies

In patients with ACS undergoing PCI who are at high bleeding risk, transition to single antiplatelet therapy (aspirin or P2Y12 inhibitor) after 1 month may be reasonable to reduce bleeding risk.

Class IIbLOE B-R§11.1 · Rec 5

11.1.1Antiplatelet Therapy in Patients on Anticoagulation Postdischarge

In patients with ACS who require oral anticoagulant therapy, aspirin should be discontinued after 1 to 4 weeks of triple antithrombotic therapy, with continued use of a P2Y12 inhibitor (preferably clopidogrel) and an oral anticoagulant to reduce bleeding risk.*

  • *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”
Class ILOE B-R§11.1.1 · Rec 1

11.2Reassessment of Lipid Levels Postdischarge

In patients after ACS, a fasting lipid panel is recommended 4 to 8 weeks after initiation or dose adjustment of lipid-lowering therapy to assess response or adherence to therapy.*

  • *Modified from the “2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ ASPC/ NLA/PCNA Guideline on the Management of Blood Cholesterol.”
Class ILOE C-LD§11.2 · Rec 1

11.4Use of Chronic Colchicine

In patients after ACS, low-dose colchicine may be reasonable to reduce risk of MACE.

Class IIbLOE B-R§11.4 · Rec 1

11.5Immunization

In patients with ACS without a contraindication, annual influenza vaccination is recommended to reduce the risk of death and MACE.

Class ILOE A§11.5 · Rec 1