Antiplatelet and Anticoagulant Therapy in the 2025 ACC/AHA Guideline for Acute Coronary Syndromes: KeyRecommendations
JACC. 2025 Jun, 85 (22) 2074–2078
The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for theManagement of Patients With Acute Coronary Syndromes (ACS), published in this issue of JACC, replaces the prior U.S. guidelines on the management of ST-segment and non–ST-segment elevation ACS. The new guideline provides anexcellent evidence-based framework for diagnosis and management of type I ACS (ie, in the setting of atherothrombosis). This Guideline Commentary highlightsthe key recommendations related to antithrombotic therapy, compares the 2025 guideline with prior American College of Cardiology (ACC)/American Heart Association (AHA) and European Society of Cardiology (ESC) recommendations, and offers reflections on recent changes and opportunities for further clarification.
With respect to antiplatelet therapy, early initiation ofaspirin and an oral P2Y12 receptor inhibitor remain Class 1 recommendations. The new guideline recommends either ticagrelor or prasugrel (Class 1, without distinction between the two) as the preferred P2Y12 inhibitor in ST-segmentelevation myocardial infarction (STEMI) or non–ST-segment elevation myocardial infarction (NSTEMI). If these agents are contraindicated, not tolerated, unaffordable, or unavailable, clopidogrel is recommended. The initiation of oral P2Y12 inhibitors before transfer to the catheterization laboratory isrecommended if there is an expected delay of >24 hours (Class 2b). In patients undergoing percutaneous coronary intervention (PCI) who have not received a P2Y12 inhibitor, intravenous cangrelor may be reasonable (Class 2b).The recommendations for the duration of dual antiplatelet therapy (DAPT) following ACS are more nuanced: The guideline recommends a default DAPT duration of 1 year after ACS for patients without high bleeding risk (Class 1),but where bleeding risk is a concern, it recommends ticagrelor monotherapy 1 month after PCI (Class 1) .Clopidogrel-based DAPT is recommended for patientswith STEMI who receive fibrinolytic therapy. In patients with NSTEMI who undergo medical therapy alone, the guideline gives a Class 1 recommendation for aspirin and ticagrelor.
In conclusion, the 2025 ACC/AHA guideline for diagnosing and managing ACS provides thoughtful, practical, and actionable recommendations for antithrombotic therapy. When paired with available resources and individualcharacteristics and values of patients, they can help clinical practice and medical practitioners until further data emerges.
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