The American College of Cardiology (ACC), American Heart Association (AHA), American College of Emergency Physicians (ACEP), National Association of EMS Physicians (NAEMSP), and Society for Cardiovascular Angiography and Interventions (SCAI) have jointly released the 2025 Guideline for the Management of Patients With Acute Coronary Syndromes (ACS), bringing significant updates to the management of ACS.¹ This revision, published in the Journal of the American College of Cardiology and Circulation, reflects the latest clinical evidence and introduces refinements in pharmacologic therapy and procedural interventions for ACS.¹

The 2025 ACS Guideline introduces critical updates in the management of ACS, incorporating the latest clinical evidence while refining treatment strategies.¹ Despite being a comprehensive document, the guideline maintains a focused scope, primarily addressing type ¹ myocardial infarction (MI).¹ The new recommendations integrate and update insights from previous guidelines to reflect the latest clinical evidence, offering a more structured and up-to-date framework for ACS management.¹

One major update is the upgrade of intracoronary imaging in percutaneous coronary intervention (PCI) procedures to a higher class of recommendation.¹ The guideline now classifies intracoronary imaging in guiding PCI as a class 1A recommendation, from class 2A, reinforcing its use in coronary interventions in complex lesions.¹ Studies have demonstrated that intravascular ultrasound (IVUS) and optical coherence tomography (OCT) improve PCI outcomes by reducing the risk of cardiac death and stent thrombosis and lowering target vessel failure rates.² These findings have strengthened the recommendation for intracoronary imaging-guided PCI over angiography-guided PCI to enhance patient safety and procedural success.²

Another key update focuses on dual antiplatelet therapy (DAPT).¹ DAPT, combining aspirin with a P2Y12 inhibitor, remains a cornerstone in ACS management.¹ To mitigate the risk of bleeding, the guideline suggests that those who tolerate DAPT with ticagrelor may transition to ticagrelor monotherapy for at least one month post-PCI.^1,3 For inpatient management, ticagrelor or prasugrel is now preferred over clopidogrel for patients undergoing PCI, based on evidence supporting its superior efficacy in reducing cardiovascular death, recurrent MI, and stent thrombosis.^1,4,5

Lipid management has also been given greater emphasis.¹ Recognizing the elevated risk of recurrent cardiovascular events post-ACS, the guideline advocates for high-intensity statin therapy in all ACS patients, with an option to initiate ezetimibe concurrently.¹ For those already on maximally tolerated statins with low-density lipoprotein cholesterol (LDL-C) ≥70mg/dL (1.8mmol/L), adding a non-statin lipid-lowering agent (such as ezetimibe, evolocumab, alirocumab, inclisiran, or bempedoic acid) is recommended.¹ Additionally, for high-risk patients with LDL-C levels between 55mg/dL-70mg/dL (1.4mmol/L-1.8mmol/L), intensifying lipid-lowering therapy is considered reasonable to further lower the risk of major adverse cardiovascular events (MACE).

The use of mechanical circulatory support (MCS) devices has been incorporated into the ACS guideline, with a specific recommendation for the microaxial flow pump in selected patients experiencing cardiogenic shock.¹ This recommendation is based on findings from the DanGer Shock trial, which demonstrated a reduction in mortality but was accompanied by an increased risk of complications, including bleeding, limb ischemia, and renal failure.⁶

In conclusion, the 2025 ACS guideline reflects the latest advancements in evidence-based cardiovascular care, particularly in PCI optimization, antiplatelet therapy, lipid management, and circulatory support for cardiogenic shock.¹ While guidelines may help shape regulatory and payer decisions, their primary purpose is to establish best practices that serve the needs of most patients while preserving clinical judgment.¹ Actively involving patients in choosing interventions based on their values, preferences, and unique clinical conditions promotes adherence and ultimately leads to better treatment outcomes.¹