Clinical Quick Reference — Management of STEMI, NSTE-ACS, and Cardiogenic Shock
This comprehensive guideline retires and replaces the 2013 STEMI and 2014 NSTE-ACS Guidelines, incorporating evidence through April 2024:
| Topic | 2013–2014 | 2025 Update |
|---|---|---|
| DAPT Duration | Standard 12 months | 12 months standard; shortened (1–3 months) or extended (30+ months) by DAPT Score & ARC-HBR |
| P2Y12 Selection | Clopidogrel acceptable | Prasugrel/Ticagrelor preferred; clopidogrel for high-bleed-risk only |
| Anticoagulation | UFH standard | UFH, bivalirudin (with 2–4h post-PCI infusion), or enoxaparin; NO fondaparinux for PCI |
| Oxygen | Routine supplemental | Only for SpO₂ <90%; NO routine oxygen (Class 3: No Benefit) |
| Statin | High-intensity; LDL <70 | High-intensity + nonstatin add-ons (PCSK9i, ezetimibe, bempedoic acid) if LDL ≥70 |
| Cardiogenic Shock | Variable multivessel approach | Culprit-only PCI recommended; NO multivessel in shock (CULPRIT-SHOCK) |
ACS classification: STEMI (ST elevation ≥1 mm limb or ≥2 mm precordial + troponin/LBBB); NSTE-ACS (ST depression, T-wave changes, or normal ECG + elevated troponin [NSTEMI] or normal [unstable angina]).
| Score | Use | Key Components | Interpretation |
|---|---|---|---|
| GRACE | NSTE-ACS & STEMI | Age, HR, SBP, Killip, Cr, troponin, ST | Low: <109; Intermediate: 109–140; High: >140 |
| HEART | ED chest pain rule-out | History, ECG, Age, Risk factors, Troponin | Low: 0–3; Intermediate: 4–6; High: 7–10 |
| TIMI | NSTE-ACS | Age ≥65, ≥3 RF, prior CAD, ASA, severe angina, ECG changes, troponin | Low: 0–2; Intermediate: 3–4; High: 5–7 |
| Scenario | Target Time | Class |
|---|---|---|
| PCI-capable, PPCI | ≤90 min from FMC | 1 |
| Non-PCI, fibrinolytic | ≤30 min from FMC | 1 |
| Rescue PCI (failed fibrinolysis) | Within 3–24 hours | 1 |
Indications: STEMI at non-PCI-capable hospital, within 12 hours of symptom onset.
| Agent | Dosing | Notes |
|---|---|---|
| Alteplase (tPA) | 15 mg bolus, then 0.75 mg/kg/30 min (max 50), then 0.5 mg/kg/60 min (max 35) | Weight-based; preferred |
| Tenecteplase (TNK) | 30–50 mg single IV bolus (weight-based) | More convenient; similar efficacy |
| Risk Category | Time Window | Class |
|---|---|---|
| Very High (shock, ongoing ischemia) | Immediate (<2 h) | 1 |
| High (elevated troponin, dynamic ST, unstable) | ≤24 hours | 1 |
| Intermediate (multiple RF, borderline troponin) | 24–72 hours | 2a |
| Low (single episode, normal troponin) | Outpatient/deferred | 2b |
| Agent | Loading (ACS) | Maintenance | Class | Key Notes |
|---|---|---|---|---|
| Aspirin | 162–325 mg (chewed) | 75–100 mg daily | 1 | Foundational; low cost |
| Prasugrel | 60 mg | 5–10 mg* | 1 | 21% ↓ MACE; avoid stroke Hx; ↑ bleeding |
| Ticagrelor | 180 mg | 90 mg BID | 1 | 16% ↓ MACE; dyspnea ~10–15%; ↑ bradycardia |
| Clopidogrel | 300–600 mg | 75 mg daily | 1 | If prasugrel/ticagrelor contraindicated; less potent |
*Prasugrel 5 mg if age ≥75 or weight <60 kg.
1 Mandatory for all ACS at presentation to reduce thrombotic events.
| Agent | Loading / Dosing | PCI Dosing | Key Notes |
|---|---|---|---|
| UFH | 60 IU/kg bolus (max 4000) | 70–100 U/kg to ACT 250–300 s | Standard; reversible with protamine; HIT risk (rare) |
| Bivalirudin | 0.75 mg/kg bolus | 1.75 mg/kg/h during PCI + 2–4h post-PCI full-dose infusion (STEMI) | 1 STEMI PPCI: ↓ bleeding & mortality; direct thrombin inhibitor; no HIT |
| Enoxaparin | 1 mg/kg SC Q12h; IV 0.5–0.75 mg/kg | Adjust based on timing; adjust if CrCl <30 | 2a Alternative to UFH; ↓ MACE in STEMI PPCI (ATOLL) |
| Fondaparinux | 2.5 mg IV or SC daily | CONTRAINDICATED (catheter thrombosis 0.9%) | Factor Xa inhibitor; DO NOT use for PCI; acceptable for fibrinolytic support |
1 Standard DAPT is 12 months of aspirin + P2Y12 inhibitor unless high-bleed/ischemic risk warrants adjustment.
| Scenario | DAPT Duration | Class | Risk Tool |
|---|---|---|---|
| Standard Risk | 12 months | 1 | Clinical judgment |
| High Bleeding Risk | 1–3 months, then P2Y12 monotherapy to 12 mo | 2b | ARC-HBR |
| High Ischemic Risk | 12–30 months | 2b | DAPT Score |
1 High-intensity statin mandatory for all ACS, regardless of baseline LDL-C.
| Intensity | Agents & Doses | LDL-C Reduction (%) |
|---|---|---|
| High-Intensity | Atorvastatin 40–80 mg; Rosuvastatin 20–40 mg | ≥50% |
| Moderate-Intensity | Atorvastatin 10–20 mg; Rosuvastatin 5–10 mg; Simvastatin 20–40 mg; Pravastatin 40–80 mg | 30–49% |
| Agent | LDL-C Reduction | Dosing | Adverse Effects |
|---|---|---|---|
| Ezetimibe | 15–25% (with statin) | 10 mg daily | LFT abnormalities (rare); myalgia |
| PCSK9 mAb (Evolocumab, Alirocumab) | ~60% | 140–420 mg SC Q2 weeks or 300–600 mg Q4 weeks | Injection site reactions; neurocognitive concerns (disputed) |
| Bempedoic Acid | ~20% | 120 mg daily | ↑ Uric acid (gout); gallstones; LFT elevations; **avoid with simvastatin >20 mg or pravastatin >40 mg** |
| Inclisiran | ~50% | 284 mg SC at 0, 3, 6 months, then Q6 months | Injection site reactions; outcomes trials ongoing |
| Drug Class | Indication | Duration | Class |
|---|---|---|---|
| Aspirin | All ACS | Lifelong (or 1–4 weeks if on anticoagulation) | 1 |
| P2Y12 Inhibitor | All ACS | 12 months (shortened or extended by risk) | 1 |
| High-Intensity Statin | All ACS | Lifelong | 1 |
| Beta-Blocker | All ACS; essential if LVEF ≤40% | Minimum 3 years; lifelong if EF ≤40% or HF | 1 |
| ACE-I / ARB | All ACS; especially EF ≤40%, DM, HTN, CKD | Lifelong | 1 |
| Nonstatin (if needed) | LDL-C ≥70 mg/dL on statin | Lifelong | 1 |
Evidence-based calculators help risk-stratify ACS patients, guide antiplatelet/anticoagulation therapy, and optimize secondary prevention:
Predicts in-hospital and 6-month mortality in ACS using age, HR, BP, Killip, troponin, Cr, ST changes.
Simplified version for rapid bedside assessment of in-hospital mortality risk in ACS.
ED-friendly chest pain risk stratification; identifies low-risk patients safe for early discharge without serial troponin.
7-point risk score for NSTE-ACS mortality and MACE; guides invasive timing decision.
Calculates ischemic vs. bleeding risk to guide DAPT duration (shortened, 12 months, or extended).
Identifies patients at high bleeding risk on DAPT; guides P2Y12 inhibitor choice and DAPT duration.
Alternative bleeding risk calculator; predicts 1-year major bleeding risk for personalized DAPT decisions.
Stroke risk in AF; guides anticoagulation decisions in ACS patients with new-onset AF.
Bleeding risk in anticoagulated patients; useful for ACS with AF on anticoagulation + DAPT.
Assesses coronary complexity; guides PCI vs. CABG decision in multivessel ACS (especially NSTE-ACS).
Evaluates completeness of revascularization; predicts outcomes in multivessel PCI cases.
Surgical risk calculator; useful in ACS patients considered for urgent CABG (left main, complex anatomy).
Stages cardiogenic shock severity (A–E); guides mechanical support strategy in ACS with shock.
Predicts kidney injury risk from contrast exposure; useful before PCI in ACS with CKD.
MDRD or CKD-EPI equations for renal function; critical for anticoagulation dosing in ACS.
Alternative GFR estimate; used for medication dosing in ACS patients with renal impairment.
Primary prevention risk calculator; useful for assessing family members and lifestyle counseling post-ACS.
Long-term risk stratification for preventive counseling in post-ACS patients and families.
Assesses QT prolongation risk; relevant for patients on antiarrhythmics or with electrolyte abnormalities post-ACS.