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CLINICAL STATEMENTS AND GUIDELINES April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e780 high index of suspicion is warranted for those who present with signs and symptoms that could be consistent with myocardial ischemia. Patients with ACS are at the highest risk for cardiovascular complications acutely, including prior to hospital presentation and during the early hospital phase. With appropriate management, this risk begins to attenuate; however, patients remain at increased risk of recurrent cardiovascular events for several months to years after an ACS.9 This may in part be related to the acute inflammatory milieu that exists after ACS that may contribute to a heightened risk of recurrent events. Although the point at which a patient transitions from being a patient with an acute ACS to one with more stable or chronic coronary disease (CCD) is incompletely defined, many of the medications indicated at discharge in patients with an ACS are similar to those for the management of a patient with CCD and should be extended more than a year beyond ACS. The long-term management of patients with ACS who are presumed to now have more stable coronary disease has been described in the 2023 AHA/ACC/ ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline.10 3 INITIAL EVALUATION AND MANAGEMENT OF SUSPECTED ACS 3.1 Initial Assessment of Suspected ACS 3.1.1 Prehospital Assessment and Management Considerations for Suspected ACS Recommendations for Prehospital Assessment and Management Considerations for Suspected ACS Referenced studies that support recommendations are summarized in the Evidence Table. COR LOE Recommendations Suspected ACS 1 B-NR 1 In patients with suspected ACS, a 12-lead ECG should be acquired and interpreted within 10 minutes of first medical contact (FMC)* to identify patients with STEMI.1,2 1 C-LD 2 In patients with suspected ACS in which the initial ECG is nondiagnostic of STEMI, serial ECGs to detect potential ischemic changes should be performed, especially when clinical suspicion of ACS is high, symptoms are persistent, or the clinical condition deteriorates.†3,4 STEMI 1 B-NR 3 In patients with suspected STEMI, immediate emergency medical services (EMS) transport to a PCI-capable hospital for primary PCI (PPCI‡) is the recommended triage strategy, with an FMC–to-first-device time system goal of ≤90 minutes.5–7 1 B-NR 4 In patients with suspected STEMI, early advance notification of the receiving PCI-capable hospital by EMS personnel and activation of the cardiac catheterization team is recommended to reduce time to reperfusion.1,8,9 *FMC indicates the time point when the patient is initially assessed by a health care professional who can obtain and interpret the ECG and deliver initial interventions (eg, defibrillation). †Modified from the “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.”10 ‡PPCI refers to emergency PCI in the setting of STEMI to achieve reperfusion in patients without previous fibrinolytic treatment. Synopsis Rapid and coordinated prehospital care plays a critical role in the optimal management of patients with suspected ACS.11 Patients with suspected ACS should be transported to the emergency department (ED) by emergency medical services (EMS).12 In contrast to transport by private vehicle, EMS transport allows for assessment, monitoring, and treatment of potentially life-threatening conditions such as arrhythmias or cardiac arrest during transport to the ED.13 In patients with suspected ACS, trained prehospital personnel should obtain a focused history and physical examination (including assessment of vital signs) and obtain at least one 12-lead ECG so that the electrocardiographic findings can facilitate next steps in Table 3. Electrocardiographic Interpretation for Patients With Suspected Acute Coronary Syndromes NSTE-ACS STEMI Electrocardiographic evidence of ischemia New or presumed new and usually dynamic horizontal or downsloping ST-segment depression ≥0.5 mm in ≥2 contiguous leads and/or T-wave inversion >1 mm in ≥2 contiguous leads with prominent R wave or R/S ratio >1 or transient ST-segment elevation. New or presumed new ST-elevation of ≥1 mm in ≥2 anatomically contiguous leads (measured at the J-point) in all leads other than V2-V3 and ≥2 mm in men ≥40 y, ≥2.5 mm in men <40 y, and ≥1.5 mm in women regardless of age in leads V2-V3.* Other observed electrocardiographic changes Many patients with NSTE-ACS have either nonspecific ST-segment or T-wave changes or a normal ECG. The absence of electrocardiographic evidence of ischemia does not exclude ACS. Posterior leads (V7-V9) should be obtained in patients with suspected left circumflex occlusion particularly in the setting of isolated ST-segment depression ≥0.5 mm in leads V1-V3. Adapted with permission from Thygesen et al.4 Copyright 2018 The European Society of Cardiology, American College of Cardiology Foundation, American Heart Association, Inc., and the World Heart Federation. Adapted from Kontos et al.11 Copyright 2022 American College of Cardiology Foundation. *ST-segment changes may be observed in other conditions including acute pericarditis, left ventricular hypertrophy, LBBB, Brugada syndrome, right ventricular pacing, Takotsubo syndrome, and early repolarization that may obscure the diagnosis of STEMI.12 New or presumably new LBBB at presentation occurs infrequently and should not be considered diagnostic of AMI in isolation; clinical correlation is required.13 A new LBBB in an asymptomatic patient does not constitute a STEMI equivalent.11 ACS indicates acute coronary syndromes; AMI, acute myocardial infarction, LBBB, left bundle branch block; NSTE-ACS, non–ST-segment elevation ACS; and STEMI, ST-segment elevation MI. Recommendations for Prehospital Assessment and Management Considerations for Suspected ACS (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026