2025 Guideline on Acute Coronary Syndromes and Myocardial Infarctions

Formal guidance provided on transfusion targets, revascularization, meds and more

New recommendations for the management of acute coronary syndrome and myocardial infarction were issued in early 2025.

More than a routine update for cardiologists, the new guidance emphasizes the importance of care in all phases of the healthcare system.

The American College of Cardiology and American Heart Association were joined by the American College of Emergency Physicians and the major societies for interventional cardiology (SCAI) and paramedics (NAEMSP) in endorsing the guidelines. PulmCCM is not affiliated with any institution or professional society.

The guidelines also continue a conceptual shift toward dissolving the classic (and arguably artificial) compartmentalization of ACS into the two categories of 1) ST-elevation MI, requiring immediate revascularization, and 2) unstable angina/non-ST elevation myocardial infarctions, many of which historically were incorrectly considered lower risk and mis-assigned to so-called “conservative” strategies.

In the past, separate guidelines were issued for UA/NSTEMI and STEMI. Although ST-elevation MIs still mandate immediate revascularization, it’s increasingly recognized that many patients with “occlusive MIs” without ST-elevations also require rapid intervention. The ACS framework has evolved to de-emphasize the classic STEMI/NSTEMI dichotomy, considering ACS as a clinical entity with or without plaque rupture.

Most of the management specified in the guidelines will be directed by cardiologists, but it’s important information for anyone taking care of patients with ACS.

What should we take away from this 95-page document?

Dual Antiplatelet Therapy for One Year, with Exceptions for Bleeding Risk Mitigation