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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 April 1, 2025 e787

disease on dialysis.4,21–30 Although these data suggest a lack of clear benefit for invasive therapies for patients with STEMI and cardiac arrest who have features indicating an unfavorable neurologic prognosis,4,7 this has not been validated in prospective trials. However, for those patients with favorable prognostic features, PPCI is associated with greater survival.4,7,27

4 Six contemporary trials9–14 have evaluated the

role of emergency angiography in patients who remain comatose after cardiac arrest, do not have ST-segment elevation on a 12-lead ECG, and are electrically and hemodynamically stable. These studies consistently demonstrated a lack of benefit to early angiography when compared with delayed or no angiography in the study population with comparable in-hospital and 6-month survival, as well as neurologic recovery.31 The relative utility of delayed coronary angiography in this population is uncertain.

4 STANDARD MEDICAL THERAPIES FOR

STEMI AND NSTE-ACS

4.1 Oxygen Therapy

Recommendations for Oxygen Therapy Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

1 C-LD 1 In patients with ACS and confirmed hypoxia

(oxygen saturation <90%), supplemental oxygen to increase oxygen saturations to ≥90% is recommended to improve myocardial oxygen supply and decrease anginal symptoms.1

3: No Benefit A 2 In patients with ACS and oxygen saturations

≥90%, routine administration of supplemental oxygen is not recommended because it does not improve cardiovascular outcomes.2–4

Synopsis Supplemental oxygen has historically been administered as part of routine care in the management of patients with suspected ACS, although evidence to suggest clinical benefit in the absence of hypoxia has been lacking.5 Randomized trials that have enrolled patients with MI and without hypoxia have not demonstrated any clinical benefit from routine use of supplemental oxygen (≥6 L/min)2–4,6 and have raised some concerns that it may increase myocardial injury by increasing vasoconstriction and increasing oxidative stress.3

Recommendation-Specific Supportive Text

1 Use of supplemental oxygen may provide benefit to

patients who present with hypoxia (peripheral capillary oxygen saturations <90%), including those who present with acute or chronic conditions that require the need for supplemental oxygen to achieve an oxygen saturation ≥90%. A systematic review and meta-analysis of RCTs in acutely ill adults from various causes without hypoxia suggested worse short- and long-term mortality with liberal compared with conservative administration of supplemental oxygen.7 These studies were unable to define the optimal oxygen saturation target range to minimize potential harm and maximize clinical benefit. The observed relationship between oxygenation and outcomes appears to be U-shaped with the lowest mortality rate described for those patients with an Spo2 of 94% to 96% at presentation.8

2 Several randomized trials have now demonstrated

a lack of cardiovascular benefit with routine use of supplemental oxygen in patients presenting with known or suspected AMI and oxygen saturations ≥90%. Although exclusion criteria varied among studies, patients with a home oxygen requirement, active bronchospasm requiring supplemental oxygen, or with cardiac arrest at presentation were excluded.2–4,6 The AVOID (Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction) trial investigated the effects of supplemental oxygen (8 L/min) in patients with STEMI and oxygen saturations ≥94% and demonstrated a lack of benefit with routine supplemental oxygen, including a possible increase in myocardial injury and infarct size.3 DETO2X-AMI (Efficacy and Outcome Study of Supplemental Oxygen Treatment in Patients With Suspected Myocardial Infarction) evaluated the use of routine supplemental oxygen (6 L/min) in 6629 patients with suspected MI and an oxygen saturation ≥90%.2 The use of supplemental oxygen did not reduce all-cause mortality at 1 year and did not reduce rehospitalization with MI.2,9 A consistent lack of clinical benefit was seen in the study for those with lower baseline oxygen saturations (90%-94%).10

4.2 Analgesics

Synopsis Patients presenting with known or suspected ACS often experience chest pain or other uncomfortable symptoms. Rapid and effective pain relief remains an important treatment goal to prevent sympathetic activation and adverse clinical sequelae (Table 6). Analgesic therapies may provide symptomatic relief, but they have not been shown to improve clinical outcomes in patients with ACS.1,2 Nitrates and opiate medications remain effective treatment options for management of pain in ACS but should be thoughtfully utilized to prevent potential harm.3–6 In particular, rapid coronary revascularization should be pursued for patients with ongoing ischemic symptoms that are not relieved with nitrates, and opiates should not be

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