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Medscape
20 hours ago
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- Medscape
Top Updates in 2025 ACS Management Guidelines
The 2025 American Heart Association/American College of Cardiology Guidelines on the management of acute coronary syndromes (ACS) were finally published recently, marking the first update after an 11-year hiatus. Despite this long gap, most acute care clinicians have remained current on ACS management through the European guidelines and other continuing medical education sources. Still, many of us have been eager to see whether the new US guidelines would contain any surprises or major breakthroughs. For those that have kept up with the literature on accelerated diagnostic protocols, troponins, anticoagulants, and related topics, the new guidelines may not feel groundbreaking. Nonetheless, the publication provided some critical reminders and a few key updates that all acute care providers should know. What follows is a selection of the most important takeaways, in my opinion, for providing acute care to patients presenting with ACS. This is not intended to be a comprehensive review of ACS management or of concepts that are already well-established in current practice. Key Points and Updated Information Posterior MI remains underdiagnosed. Missed or delayed diagnosis of acute posterior myocardial infarction (MI) remains common in acute care, largely because ST-segment elevation (STE) is lacking on the standard 12-lead ECG. Instead, these patients tend to present with ST-segment depression in the right precordial leads V1-V3. The authors remind us that the recommended method of detecting posterior MI is through the use of posterior leads in any patients with concerning symptoms and ST-depression in the right precordial leads. If ≥ 0.5 mm of STE is present in any one of the posterior leads, the diagnosis of acute posterior MI is made and justifies acute reperfusion therapy (ie, thrombolytics or immediate cardiac catheterization/percutaneous coronary intervention). Missed or delayed diagnosis of acute posterior myocardial infarction (MI) remains common in acute care, largely because ST-segment elevation (STE) is lacking on the standard 12-lead ECG. Instead, these patients tend to present with ST-segment depression in the right precordial leads V1-V3. The authors remind us that the recommended method of detecting posterior MI is through the use of posterior leads in any patients with concerning symptoms and ST-depression in the right precordial leads. If ≥ 0.5 mm of STE is present in any one of the posterior leads, the diagnosis of acute posterior MI is made and justifies acute reperfusion therapy (ie, thrombolytics or immediate cardiac catheterization/percutaneous coronary intervention). A normal ECG does not rule out ACS. The authors also remind us that the absence of electrocardiographic findings of ischemia does not rule out ACS. The authors also remind us that the absence of electrocardiographic findings of ischemia does not rule out ACS. Troponin-negative ACS ('unstable angina') still exists. The authors spend some time reviewing the pathophysiology of ACS and its correlation with troponin elevation. In this section, they remind us of a critical point: 'Unstable angina' (ie, troponin-negative ACS) still exists, even in this day of highly sensitive troponins. Just as they have reminded us that a nonischemic ECG does not rule out ACS, a negative troponin does not rule out ACS. They also remind us that even in the setting of a STEMI, a troponin test may be negative if measured within a short time from the onset of symptoms. The authors spend some time reviewing the pathophysiology of ACS and its correlation with troponin elevation. In this section, they remind us of a critical point: 'Unstable angina' (ie, troponin-negative ACS) still exists, even in this day of highly sensitive troponins. Just as they have reminded us that a nonischemic ECG does not rule out ACS, a negative troponin does not rule out ACS. They also remind us that even in the setting of a STEMI, a troponin test may be negative if measured within a short time from the onset of symptoms. Repeat ECGs are essential. The importance of serial ECG testing in patients with concerning symptoms and initially negative ECGs is emphasized. The authors state that 11% of patients ultimately diagnosed with STEMI had an initial ECG that was negative. Therefore, failure to repeat ECGs in this group of patients can result in a significant number of missed STEMIs and, in my experience, has been a common complaint in litigated cases. The importance of serial ECG testing in patients with concerning symptoms and initially negative ECGs is emphasized. The authors state that 11% of patients ultimately diagnosed with STEMI had an initial ECG that was negative. Therefore, failure to repeat ECGs in this group of patients can result in a significant number of missed STEMIs and, in my experience, has been a common complaint in litigated cases. Some patients require urgent catheterization despite the absence of STE. Another common cause of litigation is failure of healthcare providers to remember that there are groups of patients that need immediate cardiac catheterization despite the absence of STE on the ECG. In fact, the guideline indicates that catheterization should be undergone within 2 hours (Class I recommendation). These patients with ACS are categorized as unstable or very high-risk, and they include: Patients in cardiogenic shock. Patients with signs or symptoms of acute heart failure, including new or worsening mitral regurgitation or acute pulmonary edema. Patients with refractory angina. Patients with hemodynamic or electrical instability (eg, sustained ventricular tachycardia or ventricular fibrillation). Another common cause of litigation is failure of healthcare providers to remember that there are groups of patients that need immediate cardiac catheterization despite the absence of STE on the ECG. In fact, the guideline indicates that catheterization should be undergone within 2 hours (Class I recommendation). These patients with ACS are categorized as unstable or very high-risk, and they include: Blood transfusion thresholds remain uncertain. The indication for blood transfusion in patients with ACS has been a source of uncertainty for decades. Although large randomized studies to provide a clear answer are still lacking, the authors suggest (Class IIb) that in patients with ACS and acute or chronic anemia, packed cell transfusions should be provided to achieve a hemoglobin level ≥ 10 g/dL in order to reduce cardiovascular events. Viewpoint The ability to manage ACS in an evidence-based manner is critical to anyone who practices acute care medicine. These most recent US guidelines provide a fairly comprehensive review of the management of ACS, and I recommend a thorough read of the entire publication. However, I would most strongly emphasize knowledge of the points noted above because, in my experience, these have continued to be a source of confusion or missed opportunities to diagnose and properly manage this high-risk group of patients. Amal Mattu, MD, is a professor, vice chair of education, and co-director of the emergency cardiology fellowship in the Department of Emergency Medicine at the University of Maryland School of Medicine in Baltimore. Follow Dr Mattu on X.
Medscape
a day ago
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- Medscape
Revascularizing Vessels After STEMI Sees Durable Gains
For patients with ST-elevation myocardial infarction, complete revascularization of all vessels with stenosis appears to be a more effective long-term approach than targeting culprit arteries alone, according to a 10-year follow-up analysis of a Danish study. The new findings come from an analysis of patients in the DANAMI-3-PRIMULTI trial, one of several studies between 2017 and 2024 to show the value of complete revascularization, which is now recommended for patients with STEMI and multivessel disease by both US and European guidelines. But those recommendations are based on shorter-term outcomes. The question remained how long the benefits would last, said Thomas Engstrøm, MD, PhD, professor and senior consultant in the Department of Invasive Cardiology at The Heart Center, part of the University of Copenhagen, Copenhagen, Denmark. The latest data, published May 20 in the Journal of the American College of Cardiology , span the longest to date of a study of complete vs culprit-artery revascularization, he said. 'A short term of 1 or 3 years is good to see if a treatment works, but what's more important for patients is whether it is durable,' said Engstrøm, one of the authors of the original study as well as the follow-up analysis. 'Many of our patients are not that old; 10 years is not that long for a patient who has an acute myocardial infarction at 60 years of age.' The follow-up included all 627 patients in the original study, 313 of whom were randomized to culprit-artery revascularization and 314 to complete revascularization. Engstrøm said he and his colleagues manually reviewed hospital records for each patient to ensure they captured any events. Which Benefits Last? Complete revascularization was associated with better outcomes for a combination of death, recurring myocardial infarction, and recurring revascularization (hazard ratio, 0.76 compared with culprit-artery revascularization), according to the researchers. The ability of complete revascularization to prevent further revascularization accounted for the bulk of the difference, with a hazard ratio of 0.62. The results 'add further support for complete revascularization. It shows there's a persistent benefit, especially in regard to the need for repeat vascularization,' said William Fearon, MD, a professor of medicine at Stanford University, chief of interventional cardiology at Stanford University School of Medicine, Stanford, California, and the chief of the cardiology section at the VA Palo Alto Health Care System, Palo Alto, California. He was not involved in the trial. But other outcomes showed less benefit and were not statistically significant. All-cause mortality was almost the same in both groups (hazard ratio, 0.96). Cardiovascular mortality showed a 20% reduction with complete revascularization, but this difference was not statistically significant due to the low number of patients, Engstrøm said. Rates of recurrent myocardial infarction and definite stent thrombosis also were essentially the same in each group, the researchers found (odds ratio, 0.90 for both outcomes). Open Questions Other studies have shown benefit for mortality and myocardial infarction following complete revascularization. The COMPLETE trial in 2019 showed benefits for a combined outcome of cardiovascular death or myocardial infarction after 3 years (hazard ratio, 0.74), driven by a lower rate of recurrent myocardial infarction (hazard ratio, 0.68). At least two factors may explain the discrepancy in findings, Engstrøm said. The COMPLETE trial was much larger, with more than 4000 patients. 'It was more adequately powered to show effects,' Engstrøm said. 'I think the [DANAMI-3-PRIMULTI] study was relatively small relative to some others,' Fearon said. 'So, that limits the ability to look at specific endpoints that have a lower incidence.' 'What we're learning is that, for harder endpoints like [myocardial infarction], the benefit is really in more severe lesions.' DANAMI-3-PRIMULTI did not analyze patient outcomes by severity of lesions, whereas the COMPLETE trial did, he noted. In addition, revascularization was guided by different methods in the two trials. In DANAMI-3-PRIMULTI, complete revascularization was guided by fractional flow reserve (FFR) measurements, whereas the COMPLETE trial involved angiography-guided revascularization. 'The COMPLETE trial used a less stringent way of defining the lesions, by angiography. These lower-grade stenoses were not identified by FFR,' Engstrøm said. DANAMI-3-PRIMULTI did not measure FFR in patients in whom revascularization involved only the culprit artery, Fearon said. Another study reported in 2017, Compare-Acute, measured FFR in both complete and culprit-artery revascularization groups and found a lower FFR was associated with a higher rate of subsequent events, he said. The COMPLETE-2 trial currently underway is looking at whether FFR or angiography is a better way to measure blood flow in vessels, Engstrøm said. 'The COMPLETE trial showed us that angiography-guided complete revascularization is superior to culprit-artery revascularization,' said Fearon, who is on the steering committee for the COMPLETE-2 study. 'The other trials showed us that FFR-guided complete revascularization is superior, but we don't know whether FFR-guided complete revascularization is superior to angiography-guided complete revascularization.' Studies to date of complete vs culprit-vessel revascularization show 'a very uniform arrow that leads to complete revascularization,' Engstrøm said, 'but there are some corners that have not been shed light on.' Engstrøm is on the advisory board for Novo Nordisk and Abbott Medical. He has received speaker's fees from Abbott Medical, Boston Scientific, and Novo Nordisk. Fearon receives institutional research support from Abbott, CathWorks, and Medtronics. He has received consulting fees or honoraria from Shockwave Medical and from Edwards Lifesciences, and he has stock options in Heartflow.
Medscape
18-06-2025
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- Medscape
Heat, Poor Air Quality Ups Heart Attack Risk
Simultaneous exposure to ozone pollution and high temperatures significantly increases the risk for acute myocardial infarction (MI) among adults in the US, according to a recent study published in Circulation . The findings highlight the dangers of joint environmental stressors even at moderate levels and the importance of timely patient counseling. Using nationwide private insurance claims data from 2016 to 2020, researchers from Yale School of Public Health, New Haven, Connecticut, and collaborators identified 270,123 cases of acute MI in people aged 18-64 years. They found joint exposure to ground-level ozone (60 ppb) and high temperatures — roughly 90-95 °F — increased the risk for an MI by 33% compared to cooler, low-ozone days. Even under moderate conditions, such as an ozone count of 50 ppb and typical temperatures around 70 °F, the risk increased by 15%. 'The lag 0f effect means clinicians need to pay close attention to high-pollution and hot days in real time,' said Lingzhi Chu, PhD, a postdoctoral associate in the Department of Environmental Health Sciences at the Yale School of Public Health and colead author of the study 'Clinicians should emphasize to younger patients that moderate levels still pose risks' to cardiovascular health. Mary Johnson, PhD, a principal research scientist of environmental health at the Harvard T.H. Chan School of Public Health in Boston, said the findings bring much-needed attention to a younger demographic. 'This study is important because it focuses on a younger age group that is often overlooked in cardiovascular research,' said Johnson, who was not involved in the study. 'Typically, you don't think about heart attacks happening in people in the young adult category.' Johnson also noted the value of examining heat and ozone together. 'We've seen studies showing impacts from temperature and from ozone individually,' she said, 'but looking at them together, and especially looking at differences between men and women, is important.' Different Risks by Sex According to the study, women showed increased vulnerability on days with both high ozone and temperatures around 90-95 degrees, while men experienced heightened risk even when only one factor was elevated. The difference in exposure-response patterns by sex was statistically significant ( P = .016). Chu said clinicians should tailor counseling based on patient demographics. 'The sex difference that males are vulnerable to mild exposures is critical,' Chu said. 'Young men need targeted proactive counselling.' While the researchers did not assess comorbidities like hypertension or diabetes, Chu acknowledged these conditions could affect risk. 'The potential pathophysiology suggests hypertension, diabetes, or obesity may compound risks, but further research is warranted,' Chu said. Johnson said these findings should challenge assumptions in primary care because these clinicians often are the first to encounter patients of the age group studied. 'Just because you're young and healthy does not necessarily rule out the risk of a cardiac event,' she said. 'Especially if there's a combination of poor air quality and elevated temperature.' Communicating Practical Prevention Acute MI is a leading cause of morbidity and mortality globally, with approximately 800,000 cases annually in the US. Adults younger than 55 years, and particularly women, account for a growing share of acute MIs. Chu recommended several practical prevention strategies clinicians can share with patients: Adjusting the timing of outdoor activities, staying hydrated, and using cooling methods such as fans or air conditioning. She also acknowledged the challenge clinicians face in educating patients without overwhelming them. 'Clinicians may consider framing mitigation as simple behavior changes rather than drastic life changes to prevent patient overwhelm,' she said. 'Some of these simple changes — like checking air quality apps, closing windows on high-ozone days, or staying hydrated — support overall health, not just cardiovascular health.' Johnson agreed. 'While we can't individually control wildfires or ozone formation, everyone can be aware of ozone levels and temperature before going outside or doing anything physically strenuous,' she said. Health Equity Concern The study relied on data from individuals with private insurance, a limitation both Chu and Johnson acknowledged. 'That population has access to care,' Johnson said. 'But what about the uninsured or underinsured? They may be more at risk because they often live in areas with worse air quality and lack resources to adapt, like access to cooling systems or healthcare.' She added that events like sudden cardiac death may be underreported in uninsured populations. 'They don't go to the emergency room. They die before they get there,' Johnson said. 'So the real risk may actually be higher than what this study captured.' Johnson said the findings also highlight a critical shift in how clinicians should view environmental risk. 'It's accurate to say we can no longer think about air pollution and environmental risks as being linked only to chronic conditions,' said Johnson. 'There are acute consequences, too, and this study illustrates that clearly.' A study published last month in the journal Epidemiology found prolonged exposure to the particulate matter in wildfire smoke was associated with small increases in the risk for several cardiovascular diseases, especially hypertension. As climate change drives more frequent heat waves and worsens air quality, both Chu and Johnson said clinicians are on the front lines of patient education and prevention. 'Clinicians are key players in translating environmental health research into actionable prevention,' Chu said. 'This study reinforces the need to think beyond traditional risk factors.' Chu and Johnson reported no relevant financial conflicts of interest.
