Safer Antiplatelet Routines, Non-Statin Meds Feature in New Heart Attack Guidelines

In updated American recommendations for the management of acute coronary syndrome (ACS), bleeding reduction strategies on antiplatelet therapy are embraced, as are non-statin lipid-lowering therapies for secondary prevention.

The newly released 2025 ACS guideline from the American College of Cardiology and the American Heart Association still have default dual antiplatelet therapy (DAPT) as a Class I recommendation, the standard being at least 12 months of it after hospital discharge for patients with low bleeding risk.

However, the guideline, published jointly in the Journal of the American College of Cardiology and Circulation, also lays out more bleed-safe alternatives to the standard DAPT regimen for people with unstable angina, non-ST segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI):

• Selected patients can transition from DAPT to ticagrelor (Brilinta) monotherapy a month or later after percutaneous coronary intervention (PCI; Class I)
• A proton pump inhibitor can be added for those at high risk of gastrointestinal bleeding (Class I)
• De-escalation of DAPT from ticagrelor or prasugrel (Effient) to clopidogrel (Plavix) may be reasonable at least a month after PCI (Class IIb)
• Those at high bleeding risk can transition to single antiplatelet therapy (either aspirin or P2Y12 inhibitor) after 1 month (Class IIb)

These are major changes since the last DAPT guideline, from 2016, which had only mentioned shorter-duration DAPT as a consideration for ACS patients at lower ischemic risk with high bleeding risk (Class IIb).

“Patients with ACS are at the highest risk for cardiovascular complications both acutely and chronically, which emphasizes the importance of staying up-to-date on the most recent evidence presented in this guideline,” said guideline writing committee chair Sunil Rao, MD, of NYU Langone Health in New York City, in a press release. “With appropriate management, we can improve outcomes both in the hospital and over the long term.”

The new guideline also introduces non-statin lipid-lowering therapies — such as ezetimibe (Zetia), evolocumab (Repatha), alirocumab (Praluent), inclisiran (Leqvio), and bempedoic acid (Nexletol) — for secondary prevention in ACS survivors.

Statin users with an LDL cholesterol ≥70 mg/dL are strongly urged to take a concurrent non-statin lipid-lowering agent to further reduce the risk of major adverse cardiovascular events (Class I), while those with LDL cholesterol at 55-69 mg/dL, already on a maximally tolerated statin, may reasonably add one of these therapies to reduce the risk of major adverse cardiovascular events (Class IIa).

All ACS patients starting or adjusting a dose of lipid-lowering therapy should have a fasting lipid panel taken 4-8 weeks later to gauge response or additional medications that may be needed (Class I).

Another important aspect of secondary prevention is referral to outpatient cardiac rehabilitation prior to hospital discharge, which is strongly endorsed to reduce death, myocardial infarction, and hospital readmissions and improve functional status and quality of life (Class I).

Home-based cardiac rehabilitation is deemed a reasonable alternative (Class IIa), but more research is needed to see whether this model provides the same benefit as facility-based programs and makes good on its promise of better adherence, according to Rao’s group.

The 2025 guideline also now has intravascular imaging (intravascular ultrasound or optical coherence tomography) as a class I recommendation to guide PCI.

Finally, patients with STEMI and cardiogenic shock may receive a microaxial flow pump with careful attention paid to vascular access and the weaning of support (Class IIa).

The new ACS guideline was written in collaboration with and endorsed by the American College of Emergency Physicians, the National Association of EMS Physicians, and the Society for Cardiovascular Angiography and Interventions.

Guideline writers acknowledged unanswered questions in this setting, including the potential role of GLP-1 receptor agonists and colchicine after ACS.

Please enable JavaScript to view the

comments powered by Disqus.