The 2025 Guideline for the Management of Patients With Acute Coronary Syndromes: Asian Perspective
https://www.jacc.org/doi/full/10.1016/j.jacc.2025.04.011
The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for theManagement of Patients with Acute Coronary Syndromes introduces key updates that may influence global clinical practice. Given Asia’s immense population and regional diversity, assessing how these U.S.-based guidelines translate into real-world application is essential.Although grounded in robust clinical trial evidence, their relevance in Asia varies due to differences in demographics, access to treatment, health care infrastructure, and cultural context. This paper explores how these updatesintersect with regional realities, focusing on 4 key areas: 1) antithrombotic strategies; 2) lipid-lowering therapy; 3) multivessel revascularization; and 4) mechanical circulatory support in cardiogenic shock.
In South Asia, ACS management is shaped by a high burden of cardiometabolic risk, earlier disease onset, and major socioeconomic status (SES) disparities. One-thirdof patients receive care in urban tertiary centers, but most rely on under-resourced hospitals in smaller towns. Evidence-based practices are more common in high- socioeconomic status settings; elsewhere, cost and practicality drive care decisions.
1. Antithrombotic therapy is mostly dictated by affordability. Clopidogrel remains the dominant P2Y12 inhibitor. Ticagrelor is increasingly used in high-socioeconomic status urban areas, supported by local production, but is rare in rural settings and Pakistan. Prasugrel is used in <10% of patients, due to bleeding risk in those with low body weight. DAPT typically lasts 12 months; shorter courses are reserved for high bleeding risk.
2. The Lipid Association of India recommends one of the world’s most aggressive lipid-lowering strategies, using moderate- or high-intensity statins plus ezetimibe to achieve LDL-C targets of <50 mg/dL for very high risk and <30 mg/dL for extreme risk individuals, based on atheroscleroticcardiovascular disease and/or multiple high-risk features upon ACS presentation. If <20% additional LDL-C reduction is needed, bempedoic acid or bile acid sequestrants may be used; if >20%, a PCSK9i is preferred. PCSK9i and inclisiran remain largely unaffordable, though use has grown over the past year among higher socioeconomic groups, guided by the 2024 Indian Consensus Statement. Lipoprotein(a) testing is recommended at least once in all adults beginning at age 18 years.
3. Revascularization strategies depend on available infrastructure. In urban high- socioeconomic status settings, primary PCI with radial access is preferred, with staged PCIfor nonculprit lesions. In rural areas, fibrinolysis—typically tenecteplase or streptokinase—remains the primary treatment due to limited PCI access.
4. Mechanical circulatory support availability is minimal.microaxial flow pumps are present in select tertiary centers but are rarely used due to cost and training requirements. Intra-aortic balloon pump use is the mainstay. Venoarterial extracorporeal membrane oxygenation is availableonly in specialized centers, with limited use due to high cost, low expertise, and delayed presentation.
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