ACS From Plaque to Protocol 2025 updated

A Brief comprehensive presentation about Acute coronary syndrome

1. Dr / Ahmed Khaled Fahim 2025/ 10 /05 ACS 2025: From Plaque to Protocol

2. CONTENTS 01. What Is ACS? 02. Pathophysiology 03. Types & Biomarkers 04. 2025 Guidelines Update 05. Acute Management

3. CONTENTS 01 . Post-ACS Care 02 . Take-Home Messages

4. 01 What Is ACS?

5. What Is ACS? Definition & Spectrum Acute coronary syndrome is the umbrella term for sudden myocardial ischemia ranging from unstable angina to STEMI, unified by urgent presentation, shared risk factors and time-critical therapy decisions that determine survival and future cardiac function. Urgent Presentation Shared Risk Factors Time-Critical

6. Global Burden & Alarm Signs Recognizing the urgency and diverse presentations of ACS. 41s Someone has an MI every 41 seconds. Atypical Presentations Demand High Suspicion: Women: Dyspnea, Fatigue Diabetics: Atypical Pain Elderly: Syncope, Confusion Immediate ECG + High-Sensitivity Troponin is Critical.

7. 02 Pathophysiology

8. The Plaque Rupture Cascade 1. Cap Disruption Lipid-rich plaque fibrous cap ruptures. 2. Platelet Adhesion Thrombogenic core is exposed. 3. Thrombin Burst Coagulation cascade activated. 4. Occlusive Thrombus Reduces coronary flow, causing ischemia. Result: Downstream ischemia and potential irreversible necrosis.

9. Beyond Rupture Erosion & Nodular Calcification These mechanisms account for 30% of ACS , especially in younger women and diabetics. Imaging now guides whether immediate stenting is mandatory or if intensified antiplatelet therapy alone may suffice. Younger Women Higher prevalence of erosion. Diabetics More prone to calcified nodules. Imaging Guidance Intravascular imaging (IVUS/OCT) is key to diagnosis and guiding therapy.

10. 03 Types & Biomarkers

11. Classifying ACS Classification hinges on ECG and troponin. STEMI Persistent ST-elevation New LBBB Immediate reperfusion NSTEMI Elevated hs-cTn No ST-elevation Early invasive strategy Unstable Angina Ischemic symptoms ECG changes No biomarker rise

12. The High-Sensitivity Troponin Era High-sensitivity assays detect minute necrosis, reclassifying many former UA cases as NSTEMI. Faster Rule-In/Out: Serial 0/1-hour algorithms now expedite MI diagnosis. Shorter Decision Time: Significantly shortens door-to-decision time. Immediate Risk Stratification: Enables rapid patient triage and management.

13. 04 2025 Guidelines Update

14. ESC/AHA 2025 Guidelines: Key Shifts Lower Troponin Cut-offs Endorses 0/1h Pathways Integrates CT-FFR Immediate P2Y12 Loading Early Invasive Strategy ( 140)

15. Redefining MI: Types 1–5 The Universal Definition 2025 refines MI types by mechanism and introduces renal-function adjusted troponin thresholds to avoid over-diagnosis in CKD. Type 1: Spontaneous MI Type 2: Supply-Demand Imbalance Type 3: Sudden Cardiac Death Type 4: PCI-Related MI Type 5: CABG-Related MI

16. 05 Acute Management

17. STEMI Reperfusion Clock 90 min Primary PCI Goal within 90 min of first medical contact. OR 120 min Fibrinolysis If PCI delay >120 min, give pre-hospital lysis. Ancillary Therapy Aspirin • Ticagrelor • Anticoagulation • High-Dose Statin

18. NSTEMI: A Risk-Driven Strategy Very-High-Risk: Immediate Angiography High-Risk (GRACE >140): Within 24 Hours Intermediate-Risk: Within 72 Hours Discourage routine thrombus aspiration. Favor complete revascularization in multivessel disease.

19. Antithrombotic Cocktail 2025 DAPT Standard Aspirin + Ticagrelor or Prasugrel remains the cornerstone. Intensification Add low-dose Rivaroxaban (2.5 mg bid) for high ischemic risk. Duration Tailoring Shorten to 3-6 months if bleeding risk > ischemic risk.

20. 06 Post-ACS Care

21. Secondary Prevention Bundle High-Intensity Statin Atorvastatin/Rosuvastatin ACE-I/ARB For LV dysfunction SGLT2i For diabetics BP Control Target Influenza Vaccine Annual Cardiac Rehab Within 7 days

22. Long-Term Monitoring Schedule cardiology follow-up at 1, 3, and 12 months with ECG, echocardiography, and lipid panel. Troponin Testing Repeat if symptoms recur to rule out reinfarction. Implantable Loop Recorder Consider for cryptogenic sudden death survivors. Lifestyle & Support Emphasize lifestyle modification and psychosocial support.

23. 07 Take-Home Messages

24. Key Protocol Pearls: ACS 2025 1 Suspect ACS in any acute chest discomfort. 2 Use the 0/1h hs-cTn algorithm for rapid diagnosis. 3 Classify by ECG and biomarkers (STEMI vs. NSTEMI vs. UA). 4 Deliver rapid reperfusion for STEMI (PCI < 90 min). 5 Risk-stratify NSTEMI (GRACE, hs-cTn) for timing of angiography. 6 Apply 2025 antithrombotic dosing (DAPT, +/- rivaroxaban). 7 Institute guideline-directed secondary prevention before discharge.

25. Dr / Ahmed Khaled Fahim 2025/10/05 THANK YOU FOR READING ！