p.62 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e832

dyscrasias, renal failure (creatinine clearance <15 mL/min), severe hepatic impairment, or with concomitant P-glycoprotein and/or strong CYP3A4 inhibitors. Although the trials studied a dose of 0.5 mg daily, daily dosing of 0.5 mg or 0.6 mg may be considered. There are ongoing trials studying the efficacy of colchicine in patients after MI.

11.5 Immunization

Recommendation for Immunization Referenced studies that support recommendation are summarized in the Evidence Table.

COR LOE Recommendation

1 A 1.	 In patients with ACS without a contraindication,

annual influenza vaccination is recommended to reduce the risk of death and MACE.1–4

Synopsis Influenza infection is associated with increased risks of cardiovascular morbidity and mortality.5 Previous studies have shown that influenza infection may contribute to atherogenesis and plaque destabilization, thereby precipitating the occurrence of ACS.6,7 Influenza vaccine has been shown to reduce the risk of death and MACE in patients after ACS and ASCVD and should therefore be administered in patients without contraindication.1–3,5,8 Other illnesses such as COVID-19 and pneumococcal pneumonia increase risk of cardiovascular events and death in patients with ASCVD. However, randomized trial data are lacking to support routine administration of other vaccines for patients at time of hospitalization for ACS. As such, regular immunization schedules are supported for all patients per the US Centers for Disease Control and Prevention recommendations in the absence of contraindication.9

Recommendation-Specific Supportive Text

1 In the FLUVACS (Flu Vaccination in Acute

Coronary Syndromes and Planned Percutaneous Coronary Interventions) study, cardiovascular death was lower in patients who received influenza vaccination compared with the control group at both 6-month (2% versus 8%) and 1-year follow-up (6% versus 17%). The triple composite endpoint of cardiovascular death, nonfatal MI, and rehospitalization for severe recurrent ischemia at 1 year was significantly lower in the vaccine group compared with controls.2,10 Among patients admitted with MI or high-risk coronary heart disease, influenza vaccine administered within 72 hours of an invasive coronary procedure or hospitalization resulted in a lower risk of the composite primary outcome of allcause death, MI, or stent thrombosis and a lower risk of cardiovascular death compared with placebo at 1 year.1

12 EVIDENCE GAPS AND FUTURE

DIRECTIONS

The treatment of ACS has been the subject of thousands of clinical trials comprising very large numbers of patients. As such, its management is guided by the largest evidence base in clinical medicine. Despite this, there are numerous unanswered questions, evidence gaps, and areas for further study. Some of these areas have been addressed by observational studies but were not included in this guideline because the LOE was insufficient to guide clinical practice. Other areas were not included because they are less well defined and require more detailed study. This section summarizes some higher priority evidence gaps and areas for future study.

INITIAL EVALUATION AND MANAGEMENT

Although the 2025 ACS guideline recognizes the value of risk scores in estimating the risk of death or recurrent MI, limited prospective randomized data are available as to whether risk scores should be used to determine treatment strategies. The highest risk patients are those who present after a cardiac arrest. Although the data support an invasive approach in patients who have been resuscitated and who have evidence of ST-segment elevation on the postarrest ECG, any potential benefit of coronary angiography may be attenuated in those who are comatose. Similarly, it is less clear whether reperfusion with either fibrinolysis or primary PCI provides clinical benefit in patients with ST-segment elevation who present late after symptom onset (12 to 48 hours) but who are no longer symptomatic. Further research is needed to define the role of coronary angiography and revascularization in these patient subgroups.

In-Hospital Management of ACS Patients with ACS are placed on telemetry to monitor for life-threatening arrhythmias or for rhythm disturbances that may require further therapy (eg, atrioventricular block, AF). Given the length of stay for most patients with ACS has decreased significantly, the optimal duration of telemetry monitoring with contemporary management is unclear. The increasingly rapid triage and timing of invasive risk stratification also calls into question the value of “preloading” of oral P2Y12 inhibitors, with preloading defined as administering the loading dose prior to coronary angiography. As outlined in this document, clinical trials of preloading have not shown a compelling benefit when coronary angiography occurs rapidly after the patient’s clinical presentation. Nonetheless, the pharmacodynamic

Downloaded from http://ahajournals.org by on October 7, 2026