ACC-AHA 2025 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes
ACC/AHA｜循環器 / 冠動脈疾患｜92 ページ｜チャンク 931｜推奨 19 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
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| p.18 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.19 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 RCT of patients with established atherosclerotic cardiovascular disease (ASCVD), 35% of whom had a previous MI, no significant differences were observed in MACE or major bleeding for patients treated with 81 mg of aspirin daily and those treated with 325 mg daily, although a high degree of crossover between study arms was observed.5 Together, these data support the use of low-dose aspirin (75-100 mg daily) for maintenance therapy. Based on an association between aspirin dosing and outcomes in a post hoc analysis of the PLATO (Platelet Inhibition and Patient Outcomes) trial, aspirin doses of ≤100 mg daily should always be used in patients treated with ticagrelor.11 4.3.2 Oral P2Y12 Inhibitors During Hospitalization Recommendations for Oral P2Y12 Inhibitors During Hospitalization Referenced studies that support recommendations are summarized in the Evidence Table. COR LOE Recommendations All Patients With ACS (STEMI and NSTE-ACS) 1 In patients with ACS, an oral P2Y12 inhibitor should be administered in addition to aspirin to reduce MACE.1–5 2 In patients with a history of stroke or transient 3: Harm B-R ischemic attack, prasugrel should not be administered because of worse net clinical outcomes.*†4 In-Hospital Management in Patients With NSTE-ACS 3. In patients with NSTE-ACS undergoing PCI, 1 B-R prasugrel or ticagrelor is recommended to reduce MACE and stent thrombosis.4–6 | ||
| p.24 | 1 A | CLINICAL STATEMENTS AND GUIDELINES | ||
| p.24 | 1 A | ACS diagnosis for medical stabilization prior to planned angiography and PCI. In the EARLY-ACS (Early Glycoprotein IIb/IIIa Inhibition in Patients with Non–ST-segment Elevation Acute Coronary Syndrome) trial, 9406 patients with NSTE-ACS were randomized to routine upstream use of eptifibatide (within 8 hours after presentation to the hospital) versus ad hoc adjunctive use at the time of PCI among patients with NSTE-ACS.4 Ischemic outcomes were not improved and bleeding was increased in the routine upstream eptifibatide arm. An alternative approach is routine adjunctive use of a glycoprotein IIb/IIIa inhibitor at the time of PCI for patients with STEMI or NSTE-ACS. Although early trials performed prior to use of potent P2Y12 inhibitors suggested that this approach improved procedural outcomes and reduced periprocedural myocardial necrosis, studies performed among patients receiving pretreatment with clopidogrel have not confirmed reduction of ischemic events with routine adjunctive glycoprotein IIb/IIIa inhibition and have increased bleeding complications.5,11 | ||
| p.27 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.30 | 1 A | CLINICAL STATEMENTS AND GUIDELINES | ||
| p.30 | 1 A | Beta blockers decrease myocardial oxygen demand by reducing the heart rate, blood pressure, and myocardial contractility.1,3 The clinical benefit of beta blockers in patients with left ventricular ejection fraction (LVEF) <40% and stabilized HF is well established, including patients post-MI.3–5 Most of the RCT data pertaining to early use of beta-blocker therapy in STEMI were conducted in the pre-reperfusion era.3 No adequately powered RCTs have been done that examine the clinical benefit of beta blockers during hospitalization among patients exclusively with NSTE-ACS. Although most studies were conducted in patients with STEMI, early hospital initiation of beta-blocker therapy (within 24 hours) is recommended among most patients with ACS and without contraindications (eg, acute HF [Killip class II-IV], evidence of low cardiac output state or at risk for cardiogenic shock, PR interval >0.24 milliseconds, second- or third-degree heart block without a cardiac pacemaker, severe bradycardia, active bronchospasm).1,2,6 Patients with an initial contraindication to beta-blocker therapy on presentation can be reassessed after 24 hours and initiated on oral beta-blocker therapy if the initial contraindication has resolved. Further study is warranted to examine the benefit in those patients with NSTE-ACS. Although an open-label randomized trial has raised questions about the benefit of long-term beta-blocker therapy following hospital discharge in patients with ACS who have undergone coronary revascularization and have preserved left ventricular (LV) function,7 this area remains under study. Downloaded from http://ahajournals.org by on October 7, 2026 Recommendation-Specific Supportive Text 1 RCTs from both the pre-reperfusion era and in the early reperfusion era have shown that early initiation of beta-blocker therapy reduces the risk of reinfarction and ventricular arrhythmias among patients with STEMI.1–3 The COMMIT (Clopidogrel and Metoprolol in Myocardial Infarction) trial included 45 852 patients (approximately 50% received fibrinolytic therapy and 7% having NSTE- ACS) and showed that early initiation of high doses (ie, up to 15 mg intravenously then 200 mg orally daily) of metoprolol reduced the risk of reinfarction and ventricular fibrillation compared with placebo | ||
| p.33 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.34 | 1 A | related artery if the patient is asymptomatic and has a completed infarct. MACE outcomes were similar in those with an occluded infarct-related artery versus those who underwent PCI 3 to 28 days after an MI (Occluded Artery Trial [OAT])16 and results were no different at 7 years follow-up.29 Similar findings were noted in the DECOPI (Desobstruction Coronaire en Post-Infarctus) trial, which enrolled patients with an occluded artery and Q waves on the ECG presenting 2 to 15 days after symptom onset.17 5.2.2 Urgent CABG Surgery Recommendation for Urgent CABG Surgery Referenced studies that support recommendation are summarized in the Evidence Table. COR LOE Recommendation 1 In patients with STEMI in whom PCI is not feasible | ||
| p.34 | 1 A | or successful, with a large area of myocardium at risk, emergency or urgent CABG surgery can be effective to improve clinical outcomes.*1,2 2a B-NR *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”3 | ||
| p.36 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.37 | 1 A | in patients with clinical signs of failed reperfusion after fibrinolytic therapy. Several trials have demonstrated a trend toward lower mortality and significantly lower rates of recurrent MI and HF when rescue PCI is performed for failed fibrinolysis.6,7 The REACT (Rapid Early Action for Coronary Treatment) trial6 enrolled 427 patients with failed reperfusion at 90 minutes after fibrinolysis to 1 of 3 treatment arms, including rescue PCI, conservative care, or repeat fibrinolytic therapy. Rescue PCI significantly reduced the composite primary endpoint of death, reinfarction, stroke, or severe HF at 6 months compared with either conservative care or repeat fibrinolytic therapy. Meta-analyses also support lower rates of death or reinfarction when rescue PCI is performed in this setting.8,9 Minor and major bleeding and rates of stroke were significantly higher with rescue PCI.6–8 These studies were performed in the era of femoral artery access, with fewer options for antiplatelet and anticoagulant therapy. The use of radial artery access15 and the elimination of the routine use of glycoprotein IIb/IIIa inhibitors has reduced bleeding. For this reason, the balance of benefit from rescue PCI outweighs the risks for most patients with evidence of failed reperfusion after fibrinolysis. 3. Routine early angiography with the intent to perform Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.41 | 1 A | Recommendation for Use of Aspiration Thrombectomy Referenced studies that support recommendation are summarized in the Evidence Table. COR LOE Recommendation 1. Among patients with STEMI undergoing PPCI, 3: No benefit A manual aspiration thrombectomy should not be performed routinely prior to PCI given lack of clinical benefit.*1–4 *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”5 Synopsis Despite restoration of coronary patency, suboptimal myocardial perfusion resulting from distal embolization or microvascular obstruction is frequent and is associated with larger infarct size, impairment of LV function, and excess mortality rates.6,7 Removing coronary artery thrombus prior to balloon angioplasty, stent deployment, or both is an intuitive adjunct to PPCI that may yield putative clinical benefits. Routine manual thrombus aspiration performed via low profile catheters improved electrocardiographic and angiographic markers of myocardial perfusion in several clinical studies8,9 and reduced adverse events in a single-center trial.10,11 However, subsequent trials of manual aspiration thrombectomy have not demonstrated a clinical benefit.1,2,4,12,13 Similarly, results from a pooled | ||
| p.42 | 1 A | prehensive view of the vessel wall, allowing for the evaluation of plaque burden, calcification extent, lesion length, and external elastic lamina diameter before stent placement. It also facilitates the assessment of minimum stent area, malapposition, underexpansion, tissue protrusion, edge disease, and edge dissection after stent deployment.14 OCT utilizes infrared light to produce high-resolution images of the vessel wall, offering specific advantages in assessing calcium thickness, lipid presence, thrombus formation, fibroatheroma, and plaque rupture, which is particularly helpful in patients with ACS. It is also useful for examining stent strut neointimal thickness, apposition, and edge dissections. However, it has limitations regarding imaging depth and requires the injection of contrast to clear blood, limiting its utility in cases of ostial left main disease. Both IVUS and OCT play essential roles in evaluating the necessity for lesion preparation, choosing the appropriate stent size, reducing the likelihood of geographical errors, confirming proper stent expansion, identifying complications, and determining the underlying reasons for stent failure.14,15 Downloaded from http://ahajournals.org by on October 7, 2026 Recommendation-Specific Supportive Text 1 Randomized trials including patients with ACS | ||
| p.49 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.54 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 10.5.2 Postdischarge Follow-Up and Systems of Care Coordination Synopsis Transition from the hospital to home is a critical period for patients with ACS because approximately 1 in 5 patients are readmitted within 30 days of discharge.1–6 Women, individuals from traditionally underrepresented racial and Table 20. Essential Components of Patient Education Reason for hospitalization (explain reason for admission, diagnostic tests, procedural results) Tailored discussion of lifestyle modifications (AHA’s Life’s Essential 8)5 Medications (written and verbal instructions including purpose, dose, frequency, potential adverse effects of each medication; refill instructions; changes to prehospital regimen; importance of adherence) Symptom management (what to monitor for and actions to take should symptoms recur, including whom to call) | ||
| p.56 | 1 A | 11 DISCHARGE: LONG-TERM MANAGEMENT AND SECONDARY PREVENTION 11.1 DAPT Strategies in the First 12 Months Postdischarge | ||
| p.56 | 1 A | Recommendations for DAPT Strategies in the First 12 Months Postdischarge Referenced studies that support recommendations are summarized in the Evidence Table. COR LOE Recommendations Default Duration of DAPT 1 In patients with ACS who are not at high bleeding risk, DAPT with aspirin and an oral P2Y12 inhibitor should be administered for at least 1 year to reduce MACE.1–6 | ||
| p.62 | 1 A | CLINICAL STATEMENTS AND GUIDELINES Downloaded from http://ahajournals.org by on October 7, 2026 |