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Acute coronary syndromes

Current 2025 US triage, antithrombotic, invasive, revascularization and post-discharge priorities for unstable angina, NSTEMI and STEMI.

JurisdictionUnited States
Source check2026-08-20
Clinical reviewiatroX editorial team 路 Clinical editorial review 路 reviewed 2026-08-20 路 due 2027-08-20
AudienceUnited States healthcare professionals
This is an iatroX educational summary of named United States sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. Use the named authority, current FDA labeling, applicable state law, payer rules and local protocol where relevant.

Scope of this summary

Adults with suspected or confirmed unstable angina, non鈥揝T-elevation myocardial infarction or ST-elevation myocardial infarction. This educational page summarizes priorities from the 2025 multisociety guideline; it does not replace EMS destination, STEMI activation, antithrombotic dosing or catheterization-laboratory protocols.
sources for this section:ACC/AHA ACS 2025

The Bottom Line

  • Recognize ACS symptoms and activate emergency services; obtain ECG and serial high-sensitivity troponin without delaying reperfusion for STEMI.
  • Dual antiplatelet therapy is standard in ACS. For patients undergoing PCI, ticagrelor or prasugrel is generally preferred to clopidogrel when eligible, with treatment individualized for bleeding and anticoagulation.
  • An invasive strategy is recommended for intermediate- or high-risk NSTE-ACS, and complete revascularization is recommended in appropriate STEMI and NSTE-ACS patients.
  • Use radial access for PCI to reduce bleeding and vascular complications when feasible; in cardiogenic shock, emergency culprit-vessel revascularization is indicated but routine nonculprit PCI at the same sitting is not recommended.
  • Secondary prevention begins before discharge: high-intensity lipid lowering, cardiac rehabilitation, tobacco treatment, risk-factor control and early lipid reassessment are core care.
sources for this section:ACC/AHA ACS 2025

Practical clinical workflow

1
Activate EMS or the institutional ACS pathway, assess stability, obtain a 12-lead ECG promptly and use serial high-sensitivity troponin and repeat ECGs as the protocol directs.
2
Classify STEMI, NSTE-ACS or an alternative diagnosis; assess ischemic and bleeding risk, kidney function, prior antithrombotics and need for long-term anticoagulation.
3
Start protocol-directed antiplatelet, anticoagulant and anti-ischemic therapy and arrange immediate reperfusion or risk-timed invasive angiography.
4
Coordinate culprit and complete revascularization strategy with the heart team when disease complexity, shock or surgical anatomy requires it.
5
At discharge, reconcile antithrombotic duration, lipid therapy, rehabilitation, ventricular function, smoking treatment, follow-up and warning symptoms.
sources for this section:ACC/AHA ACS 2025

Safety boundaries and escalation

  • Cardiogenic shock, refractory ischemia, malignant arrhythmia, acute heart failure or mechanical complication requires immediate critical-care and revascularization escalation.
  • Balance ischemic benefit against bleeding, prior intracranial hemorrhage, active bleeding, planned surgery, kidney function and concurrent anticoagulation before antithrombotic selection.
  • Do not give a fibrinolytic, P2Y12 inhibitor or anticoagulant from a generic summary without confirming diagnosis, contraindications, timing and the current local protocol.
  • New recurrent pain, dyspnea, syncope, bleeding or neurologic symptoms after discharge warrants urgent reassessment.
sources for this section:ACC/AHA ACS 2025

Localization

The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline replaces the older separate US STEMI and NSTEMI pathways. Regional EMS systems, PCI capability, insurer access and health-system transfer agreements determine implementation.
sources for this section:ACC/AHA ACS 2025

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. American College of Cardiology and American Heart Association Joint Committee on Clinical Practice Guidelines2025 Guideline for the Management of Patients With Acute Coronary SyndromesDOI 10.1161/CIR.0000000000001309 路 published 2025-02-27 路 accessed 2026-08-20
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