New Guidelines for the Management of Acute Coronary Syndromes

The American Heart Association (AHA) and the American College of Cardiology (ACC) recently issued updated clinical guidelines for the management of patients with acute coronary syndromes (ACS).

Sunil Rao, MD, director of interventional cardiology at NYU Langone Heart and deputy director of the Leon H. Charney Division of Cardiology, led this effort as the chair of the guideline writing committee. The guideline, published in Circulation and the Journal of the American College of Cardiology, integrates the latest evidence and recommendations to improve quality of care and outcomes.

“Patients with ACS face the highest risk for both acute and chronic cardiovascular complications, underscoring the importance of staying current with the latest evidence in this guideline,” says Dr. Rao. “By providing appropriate management, we can improve outcomes both during hospitalization and in the long term.”

Key Updates in ACS Management

The guideline covers angina and myocardial infarction (MI)—both ST-elevation and non-ST-elevation MI, with a primary focus on type 1 MI.

The most important updates for clinicians include the following:

• Dual Antiplatelet Therapy (DAPT)
• Percutaneous Coronary Intervention (PCI)
• Cardiogenic Shock Management
• Secondary prevention strategies

DAPT Recommendations

Most recommendations on the use of antiplatelet therapy were unchanged from the previous version, including a class 1 recommendation to use DAPT with aspirin and a P2Y12 inhibitor for at least 12 months after hospitalization as the standard in patients with low bleeding risk to reduce the risk of recurrent MI.

For those with high bleeding risk, alternative therapies and durations are recommended. The guidelines also recommend prasugrel or ticagrelor over clopidogrel in patients with ACS who are undergoing PCI.

PCI Recommendations

Intracoronary imaging is recommended to guide PCI in patients with complex coronary lesions. Since the last update, new randomized trials have demonstrated that intracoronary-guided PCI is superior to angiography-guided PCI, leading to better clinical outcomes.

In terms of procedural techniques, a radial approach is preferred over femoral approach in those undergoing emergent PCI to reduce the risk of bleeding, vascular complications, and death.

Cardiogenic Shock Management

For the first time, the guidelines introduce new evidence on the use of a microaxial flow pump in select patients with cardiogenic shock related to acute MI. This class 2a recommendation is based on results from the DanGer Shock trial.

“This is the first time since 1999 we have a treatment strategy that reduces mortality in acute cardiogenic shock,” says Dr. Rao. “This is a very important update.”

Prioritizing Secondary Prevention

Other recommendations pertain to post-ACS care, including best practices around secondary prevention. The guidelines recommend the following:

• Lipid Management: A fasting lipid panel four to eight weeks post-initiation or modification of lipid-lowering therapy to optimize treatment
• LDL Cholesterol Control: For patients on maximally tolerated statin therapy with LDL ≥70 mg/dL, adding a non-statin agent such as ezetimibe or PCSK9 inhibitor is strongly recommended
• Cardiac Rehabilitation: Referral to outpatient cardiac rehab prior to discharge is recommended to improve survival, reduce the risk of recurrent MI, and enhance quality of life

“It’s been quite a while since the last version, and the field moves quickly,” explains Dr. Rao. “Clinicians should look to the updated guideline document to understand how to best incorporate new evidence into their clinical practice.”

The guideline was written in collaboration and endorsed by multiple professional societies, including the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), and the Society for Cardiovascular Angiography and Interventions (SCAI).