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CLINICAL STATEMENTS AND GUIDELINES April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e822 Recommendation-Specific Supportive Text 1 Admission to the CICU and optimal length of stay in the CICU after an MI should be based on patients’ risk profile and clinical stability, while considering the patient’s baseline cardiac risk and comorbidities. Patients with ACS with continuing/ ongoing angina, hemodynamic instability, uncontrolled arrhythmias, or a large MI with HF, cardiogenic shock, or both, should be admitted to a CICU.1,2 Patients with ongoing ischemic symptoms should be preferentially triaged for cardiac catheterization whenever possible. Stable patients with ACS and without recurrent ischemia, significant arrhythmias, pulmonary edema, or hemodynamic instability do not need CICU admission and can be admitted to an intermediate care or telemetry unit. Clinical predictors may be useful for helping identify patients who will require CICU care. For example, the ACTION ICU risk score for CICU admission integrates 9 variables on presentation to the ED including: signs or symptoms of HF, initial heart rate, initial SBP, initial troponin, initial serum creatinine, prior revascularization, chronic lung disease, ST-segment depression, and age >70 years.3 10.2 Management of Anemia in ACS Recommendation for Management of Anemia in ACS Referenced studies that support recommendation are summarized in the Evidence Table. COR LOE Recommendation 2b B-R 1. In patients with ACS and acute or chronic anemia, blood transfusion to achieve a hemoglobin level ≥10 g/dL may be reasonable to reduce cardiovascular events.1 Synopsis Anemia is common in patients with ACS and is associated with worse short- and long-term outcomes.2–4 Anemia is associated with adverse outcomes irrespective of whether the anemia is chronic and due to comorbid conditions, or acute and the result of bleeding related to antithrombotic therapy and/or invasive procedures. The adverse effects of anemia may be due to decreased myocardial oxygen delivery, increased myocardial oxygen demand due to increased cardiac output, or the avoidance of potentially beneficial antithrombotic drugs and/or procedures. In observational studies, blood transfusion has been associated with worse clinical outcomes.5–8 Randomized trials in medically ill patients and those undergoing cardiac surgery have demonstrated similar or better outcomes with a restrictive transfusion strategy (targeting a blood hemoglobin level around 8 g/dL) than with a liberal transfusion strategy (targeting a blood hemoglobin level around 10 g/dL).9–11 However, randomized trial evidence for populations with ACS suggests possible clinical benefit for a more liberal transfusion strategy targeting a hemoglobin level above 10 g/dL compared with targeting a hemoglobin level above 7 g/dL to 8 g/dL.1,12,13 Recommendation-Specific Supportive Text 1 The MINT (Myocardial Ischemia and Transfusion) trial randomly assigned 3504 patients with acute STEMI or NSTEMI and anemia with a blood hemoglobin level of <10 g/dL (13% with recent bleeding) to a restrictive transfusion strategy (transfusing if the hemoglobin level was <7-8 g/dL) or a liberal transfusion strategy (transfusing if the hemoglobin level was <10 g/dL).1 Patients were ineligible for enrollment if they had uncontrolled bleeding, were receiving palliative treatment, or were scheduled to have cardiac surgery. Transfusion could be delayed for patients with volume overload or until day of dialysis in patients with end-stage renal disease. The primary outcome of 30-day death or recurrent MI occurred in 16.9% of patients in the restrictive strategy and 14.5% of patients in the liberal strategy (relative risk, 1.15 [95% CI, 0.99-1.34]; P =0.07). Death occurred in 9.9% of patients in the restrictive strategy and 8.3% of patients in the liberal strategy (relative risk, 1.19 [95% CI, 0.94-1.49]), and cardiac death occurred in 5.5% of patients in the restrictive strategy and 3.2% of patients in the liberal strategy (relative risk, 1.74 [95% CI, 1.26-2.40]). Although the MINT trial did not demonstrate a statistically significant reduction in its primary endpoint, the results suggest that a liberal blood transfusion strategy targeting a hemoglobin level around 10 g/dL may provide short-term clinical benefit over a restrictive transfusion strategy targeting a hemoglobin level above 7 g/dL or 8 g/dL in patients with AMI and anemia. 10.3 Telemetry and Length of Stay Recommendation for Telemetry and Length of Stay COR LOE Recommendation 1 C-LD 1 In patients with ACS, telemetry monitoring is recommended to reduce cardiovascular events with duration determined by cardiac risk.1,2 Synopsis Advances in vascular access methods, coronary revascularization, and concomitant medical therapies have contributed to shortening length of stay and further facilitated changes in discharge patterns after PCI in the setting of ACS. There remains limited evidence Downloaded from http://ahajournals.org by on October 7, 2026