ACS ACC 2025 part 2

Question 1

Beta-Blocker Therapy ?

Answer 1

In patients with ACS without contraindications, early
(<24 hours) initiation of oral beta-blocker therapy is recommended to reduce risk of reinfarction and ventricular arrhythmias

Question 2

Recommendations for Renin-Angiotensin-Aldosterone System Inhibitors

Answer 2

1. In high-risk patients with ACS (LVEF ≤40%,
   hypertension, diabetes mellitus, or STEMI with anterior location), an oral angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) is indicated to reduce all-cause death and MACE. (1B)
2. In patients with ACS and LVEF ≤40%, and
   with HF symptoms and/or diabetes mellitus, a mineralocorticoid receptor antagonist is indicated to reduce all-cause death and MACE (1B)
3. In patients with ACS who are not considered high risk, an oral ACEi or an ARB is reasonable to reduce MACE (2A)

Question 3

Recommendations for PPCI in STEMI ?

Answer 3

1. In patients with STEMI presenting <12 hours
   after symptom onset, PPCI should be performed with a goal of FMC to device activation of ≤90 minutes, or ≤120 minutes in patients requiring hospital transfer, to improve survival. (1B)
2. In patients with ACS and cardiogenic shock or hemodynamic instability, emergency revascularization of the culprit vessel by PCI or CABG is indicated to improve survival, irrespective of time from symptom onset (2A)
3. In patients with STEMI presenting 12 to 24 hours after symptom onset, PPCI is reasonable to improve clinical outcomes. (2A)
4. In patients with STEMI presenting >24 hours after symptom onset with the presence of ongoing ischemia or life-threatening arrhythmia, PPCI is
   reasonable to improve clinical outcomes
   2A
5. In patients who are stable with STEMI who have a totally occluded infarct-related artery >24 hours after symptom onset and are without evidence of ongoing ischemia, acute severe HF, or life-threatening arrhythmia, PPCI should not be performed due to lack of benefit (III)

Question 4

Urgent CABG Surgery :

Answer 4

In patients with STEMI in whom PCI is not feasible or successful, with a large area of myocardium at risk, emergency or urgent CABG surgery can be effective to improve clinical outcomes

Question 5

Absolute Contraindications for fibrinolysis ?

Answer 5

Absolute Contraindications

Any prior ICH

Known structural cerebral vascular lesion
(eg, arteriovenous malformation)

Known malignant intracranial neoplasm (primary or metastatic)

Ischemic stroke within 3 mo except acute

ischemic stroke (<4.5h of onset)

Suspected aortic dissection

Active bleeding or bleeding diathesis (excluding menses)

Significant closed-head or facial trauma within 3 mo

Intracranial or intraspinal surgery within 2 mo

Severe uncontrolled hypertension (unresponsive to therapy) (SBP >180
mm Hg or DBP >110 mm Hg)

Question 6

Use of Aspiration Thrombectomy

Answer 6

class III

Question 7

Management of Multivessel CAD in STEMI

Answer 7

In selected, hemodynamically stable patients with STEMI and multivessel disease (MVD), after successful PCI of the infarct-related artery, PCI of significantly stenosed* (>50% LM or > 70% non LM) noninfarct-related arteries is recommended to reduce the risk of death or MI and improve angina-related quality of
life (2A)

2. In appropriate patients with STEMI and complex MVD, after successful PCI of the infarct-related artery, elective CABG surgery for significantly stenosed noninfarct-related arteries involving the left anterior descending artery or left main
   disease is reasonable to reduce the risk of
   cardiovascular events.
   (2B)
3. In selected hemodynamically stable patients with STEMI and low-complexity MVD (those not intended for CABG surgery), multivessel PCI of significantly stenosed noninfarct-related arteries at the time of PPCI may be preferred over a staged approach to reduce the risk of cardiovascular events

Question 8

Management of Multivessel CAD in NSTE-ACS

Answer 8

In stable patients with NSTE-ACS with MVD but without left main stenosis who are not intended for CABG surgery and undergoing culprit-lesion PCI, PCI of significant nonculprit lesions (at the time of the index procedure or as a staged procedure) is recommended to reduce the risk of
MACE

Question 9

In patients with NSTE-ACS and MVD, CABG surgery may be preferred over multivessel PCI in any of the following situations :

Answer 9

Significant left main coronary stenosis with high-complexity CAD

Multivessel CAD with complex or diffuse CAD

Diabetes mellitus and MVD with the involvement of the LAD

Multivessel CAD or complex left main CAD with severe left ventricular dysfunction

Question 10

ICD implantation ?

Answer 10

1. In patients post MI, implantable cardioverterdefibrillator (ICD) implantation is recommended in selected patients with an LVEF ≤40% at least 40 days post MI and at least 90 days postrevascularization to reduce death. 2A
2. In patients post ACS, ICD implantation is
   reasonable in patients with clinically relevant ventricular arrhythmias >48 hours and within 40 days post MI to improve survival. 2B
3. In patients early after MI, usefulness of a
   temporary wearable cardioverter-defibrillator is uncertain in patients with an LVEF ≤35% to improve survival