Cardiology
Loren Bonner
The field of cardiology is evolving rapidly, which means guidelines must keep up. In early 2025, the American Heart Association, along with the American College of Cardiology, released an updated clinical practice guideline to improve care for patients experiencing acute coronary syndrome (ACS). The condition includes a group of acute cardiovascular disorders defined by sudden reduced blood flow to the heart muscle, with symptoms ranging from chest pain and shortness of breath to dizziness.
The guideline includes recommendations on antiplatelet therapy, the use of intra-coronary imaging, the management of cardiogenic shock, lipid-lowering strategies, controlling anemia, and more.
“There are strong data that following guideline-recommended treatment strategies improves survival,” said guideline chair Sunil V. Rao, MD. He noted that patients with ACS are at the highest risk for cardiovascular complications both acutely and chronically. However, with appropriate management—and staying up to date on the most recent evidence—out-
comes for these patients can improve not only in the hospital, but over the long term.
“Over the ensuing 12 years, there have been multiple randomized trials that clinicians need to be aware of and incorporate into their daily practice,” said Rao.
The last set of guidelines for the management of ACS were released in 2013.
Medication updates
In the new guideline, the biggest changes to pharmacotherapy include the type and duration of antiplatelet therapy for patients with ACS.
“While 12 months of dual antiplatelet therapy is still recommended, we have included several strategies to reduce bleeding risk,” said Rao, who is director of interventional cardiology at NYU Langone Health.
Dual antiplatelet therapy, which comprises aspirin plus a P2Y12 inhibitor, is already recommended for patients with ACS. While it reduces the risk of recurrent myocardial infarction, it can increase bleeding risk in some patients. Dual antiplatelet therapy is recommended for at least 12 months after hospital discharge for patients with low bleeding risk.
Several strategies are recommended for patients with a higher bleeding risk. These include avoiding aspirin in patients who are on oral anticoagulation, reducing the potency of the P2Y12 inhibitor after a certain period of dual antiplatelet therapy treatment, and even shortening the durations of dual antiplatelet therapy in select patients.
“Pharmacists are an integral part of the cardiology care team,” said Rao. “They are invaluable in helping to avoid dangerous drug–drug interactions and in educating patients about the indications for their medications and the importance of adherence.”
Specific recommendations
Secondary prevention following ACS, focused on reducing progression, recurrence, or complications, is fundamental in the recovery process, according to the guideline authors. Specifically, the guideline includes the following recommendations:
A fasting lipid panel 4 to 8 weeks after initiation or a dose adjustment of lipid-lowering therapy to gauge response or additional medications that may be needed.
Patients with ACS on a maximally tolerated statin with an LDL cholesterol greater than or equal to 70 mg/dL should add a concurrent nonstatin lipid-lowering agent, such as ezetimibe, evolocumab, alirocumab, inclisiran or bempedoic acid, to further reduce the risk of major adverse cardiovascular events.
For patients with a lower LDL cholesterol of 55 mg/dL to 69 mg/dL already on a maximally tolerated statin, it is also reasonable to add a nonstatin to reduce the risk of major adverse cardiovascular events.
Referral to outpatient cardiac rehabilitation prior to hospital discharge to reduce death, myocardial infarction, and hospital readmissions and improve functional status and quality of life. ■