Acute coronary syndrome guideline includes updates on blood thinners, circulatory support
Key takeaways:
- A guideline for managing patients with acute coronary syndrome was issued by several U.S. societies.
- The document details recommendations for duration of antiplatelet therapy and more.
The American College of Cardiology and American Heart Association issued updated practice guidelines for the management of patients with acute coronary syndrome.
The document was 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. It was published in Circulation and the Journal of the American College of Cardiology.
“In the past, the guidelines were separated into STEMI and non-ST segment elevation and ACS. In this document, we combined both and narrowed the focus to specifically type 1 MI, not type 2 or MI with nonobstructive coronary arteries (MINOCA). MINOCA is covered in the chest pain guidelines,” Sunil V. Rao, MD, FACC, FSCAI, professor of medicine and director of interventional cardiology at NYU Langone Health System, editor-in-chief of Circulation: Cardiovascular Interventions and chair of the guideline writing committee, told Healio. “It’s been quite a while since the last document and the field moves quickly. There are multiple randomized trials now influencing clinical practice that clinicians are either already incorporating into their practice or are looking to an updated guidelines document to understand how to incorporate those things into their clinical practice.”
DAPT duration and mechanical circulatory support
“The big changes revolve around, for example, antiplatelet therapy and de-escalation strategies for patients who are high bleeding risk and intracoronary imaging,” Rao said.
Dual antiplatelet therapy with aspirin plus an oral P2Y12 inhibitor is still indicated for at least 12 months for patients with ACS who are not at high risk for bleeding, and ticagrelor (Brilinta, AstraZeneca) or prasugrel is recommended over clopidogrel for those undergoing PCI, according to the document.
“Changes to DAPT duration are dependent on bleeding risks,” Rao told Healio. “If you are high bleeding risk, the guidelines mention multiple de-escalation strategies, such as de-escalation to P2Y12 monotherapy, or in patients who have an indication for oral anticoagulation, dropping aspirin, for example.”
In addition, the updated guideline now contains a class I recommendation for radial-access PCI guided by intracoronary imaging for patients with complex lesions.
“Similarly, there are new data on the use of mechanical support devices for acute MI-related cardiogenic shock from the DanGer-Shock trial, and that has also been incorporated into the new guidelines,” Rao said.
As Healio previously reported, routine use of a microaxial flow pump (Impella CP, Abiomed), on top of standard care, demonstrated lower risk for death compared with standard care alone for patients with STEMI and cardiogenic shock.
The class IIA guideline recommendation is specific to the device studied in DanGer-Shock and the trial’s patient population, Rao said.
PCI of multivessel disease and current knowledge gaps
“Other recommendations that have been either carried over or may be slightly different are, for example, for patients who have multivessel disease with STEMI,” Rao told Healio.
The updated guidelines now give a class I recommendation to the PCI of nonculprit lesions in patients with STEMI via either single or staged procedures, but leans slightly toward complete revascularization of nonculprit multivessel disease during a single procedure. However, PCI of nonculprit lesions during emergency revascularization is not recommended for patients with ACS and cardiogenic shock, according to the document.
The recommendation is based on the results of the COMPLETE trial, for which Rao was a co-investigator.
As Healio previously reported, complete revascularization was superior compared with culprit lesion-only PCI for lowering risk for CV death or MI in this patient population.
“For multivessel disease and non-STEMI, it is a bit different. We don’t have a lot of data. That’s a knowledge gap. There are ongoing trials, but it is hard to give a strong recommendation to doing PCI of multiple vessels in the setting of non-STEMI,” Rao said. “So we did not give it a class I recommendation. But there are trials that are going to be released in the next few years that will fill that gap.
“We also need more data on some of the newer drugs and their role in ACS. GLP-1 receptor agonists, for example, show lots of benefits. But these drugs are almost entirely studied in the stable setting,” Rao told Healio. “With respect to potentially the most important thing we can do, which is long-term secondary prevention, we need to understand how we can implement better secondary prevention strategies, and we need to understand how we can bring cardiac rehabilitation, for example, to the patient rather than having the patient go to the cardiac rehab. It’s highly underused. Is home-based cardiac rehabilitation after acute MI just as effective? We do not know.”
Please see the guideline document for full details on the updated recommendations for the management of ACS.
For more information:
Sunil V. Rao, MD, FSCAI, FACC, can be reached at 550 First Ave., 14th Floor, New York, NY 10016.
References:
- ACC, AHA issue new acute coronary syndromes guideline. https://newsroom.heart.org/news/acc-aha-issue-new-acute-coronary-syndromes-guideline. Published Feb. 27, 2025. Accessed Feb. 27, 2025.
- Rao SV, et al. J Am Coll Cardiol. 2025;doi:10.1016/j.jacc.2024.11.009.
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