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CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e776

Additional relevant studies, which were published through April 2024 during the guideline writing process, were also considered by the writing committee and added to the evidence tables when appropriate. The final evidence tables summarize the evidence used by the writing committee to formulate recommendations. References selected and published in the present document are representative and not allinclusive.

1.2 Composition of the Writing Committee

The writing committee consisted of general cardiologists, interventional cardiologists, cardiovascular surgeons, critical care cardiologists, emergency physicians, cardiac imaging experts, advanced practice nurses, clinical pharmacists, and lay/patient representatives. The writing committee included representatives from the AHA, ACC, American College of Emergency Physicians (ACEP), National Association of EMS Physicians (NAEMSP), and Society for Cardiovascular Angiography and Interventions (SCAI). Appendix 1 of the current document lists writing committee members’ comprehensive and relevant RWI.

1.3 Guideline Review and Approval

The Joint Committee appointed a peer review committee to review the document. The peer review committee comprised individuals nominated by the ACC, AHA, and the collaborating organizations. Reviewers’ RWI information was distributed to the writing committee and is published in this document (Appendix 2). This document was approved for publication by the governing bodies of the ACC and the AHA and was endorsed by ACEP, NAEMSP, and SCAI.

1.4 Scope of the Guideline

The scope of the “2025 ACC/AHA/ACEP/NAEMSP/ SCAI Guideline for the Management of Patients With Acute Coronary Syndromes” (referred to hereafter as the “2025 ACS guideline”) is to incorporate new evidence since the publication of the “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction,”1 the corresponding “2014 AHA/ACC Guideline for the Management of Patients With Non– ST-Elevation Acute Coronary Syndromes,”2 and the “2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction.”3 The 2025 ACS guideline and the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization”4 retire and replace, respectively, the “2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease.”5 This guideline primarily focuses on the management of type 1 acute myocardial infarction (AMI). It can be challenging to differentiate type 1 versus type 2 MI. In cases of uncertainty and depending on the benefits/risks of a specific diagnostic or therapeutic intervention, it may be appropriate to err on the side of considering an event a type 1 acute coronary syndrome (ACS) event until established to be otherwise.

In the United States, an estimated 805 000 AMIs occur annually of which 605 000 are first MI events and 200 000 are recurrent.6–8 Although significant morbidity and mortality are associated with MI, 30-day and in-hospital mortality rates after ST-segment elevation myocardial infarction (STEMI) have declined in part as a result of timely reperfusion and implementation of evidencebased secondary prevention.9 From 2011 to 2021 in the United States, the annual death rate attributable to coronary heart disease declined by 15.0%.6 The economic impact of MI is also substantial, with the total annual cost estimated at $84.9 billion, including direct medical expenditures and indirect lost productivity and wages.10,11 The incidence of MI is higher among Black males compared with non-Hispanic White males for reasons that are believed to be multifactorial.12,13 Potential factors that may contribute to this disparity include a higher prevalence of risk factors for CAD, less use of guidelinerecommended medications post-MI, and socioeconomic factors.14–19 In addition to racial disparities, there are sex-related disparities in the prevalence, presentation, treatment, and outcomes of ACS even after adjusting for confounding factors such as income, geography, and education.20 Women tend to present with ACS on average 10 years later than men and with a greater burden of CVD risk factors. Although chest pain remains the most common symptom of AMI, women are more likely than men to present with accompanying non–chest pain symptoms.21–24 A delay in recognition of these symptoms can result in delays in presentation, diagnosis, and timely treatment of women with ACS. Studies have also shown that women presenting with ACS are less likely to be correctly diagnosed with an ACS, receive guideline-directed medical therapy,25–27 and/or undergo coronary revascularization when indicated.28,29 Bridging these racial and sex gaps will require continued provider education, better understanding of barriers to accessing quality care and guideline-directed medical therapy, and changes at the community and legislative level to address social determinants of health such as income, employment status, neighborhood safety, and access to healthy foods. In developing the 2025 ACS guideline, the writing committee reviewed previously published guidelines and related scientific statements. Table 1 contains a list of these publications deemed pertinent to this writing effort. It is intended for use as a resource, obviating

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