#GuidelinesSaturday ACC/AHA🧵 STEMI- 2025 ACC/AHA ACS Guidelines #Key recommendations from Rao et al., Circulation 2025 🚨 STEMI ⬇️⏱️#TIMEISMYOCARDIUM 🟥 Class 1: 🥇 12-lead ECG within 10 minutes of first medical contact (FMC) 🥇 Class 1: EMS should notify the cath lab before arriving 🥇 Class 1: FMC-to-device goal ≤90 min (direct); ≤120 min (transfer) 🛑 Every 30-min delay in PPCI → 7.5% increase in relative 1-year mortality risk. #PPCI 🫀 PPCI is the preferred reperfusion strategy — but timing matters: 🟥 [Class 1] (LOE A) ✅ <12h from symptom onset → PPCI 🟡 [Class 2a] 🟡 12–24h → PPCI reasonable 🟡 >24h ongoing ischemia/arrhythmia → PPCI reasonable 🛑 [Class 3: HARM] 🚫 >24h, stable, totally occluded, no ischemia → PPCI not recommended #ReperfusionStrategy 💉 When you can't do primary PCI… If anticipated FMC-to-device >120 min → give fibrinolysis (Class 1, LOE A) within 12h of symptom onset. 👌 Preferred agents: tenecteplase, reteplase, alteplase (fibrin-specific) After lysis → transfer ALL patients to PCI center immediately. Early angiography at 2–24h recommended (Class 1, LOE B-R) #Fibrinolysis #PharmacoinvasiveStrategy 🤛 Radial access is the new standard (Class 1, LOE A) Meta-analysis of 7 RCTs (n=48,600 ): ↓ 24% relative reduction in all-cause death ↓ 51% reduction in major bleeding ↓ 62% reduction in vascular complications #RadialAccess#PCIAccess 💊 Antiplatelet therapy in STEMI 🟥 [Class 1](LOE A) ✅️ Aspirin loading dose 162–325 mg → then 75–100 mg/day ✅️ Clopidogrel fibrinolysis 🟥 [Class 1](LOE B-R) ✅️ Add ticagrelor or prasugrel — preferred over clopidogrel for PPCI 🛑 [Class 3: HARM] 🚫 Prasugrel contraindicated in prior stroke/TIA #DAPT#Ticagrelor#Prasugrel 🩸 Anticoagulation during PPCI 🟥 UFH — standard, Class 1 (C-EO) 🟥 Bivalirudin — now Class 1 for STEMI! (LOE B-R) — the BRIGHT-4 trial showed ↓ all-cause death ↓ stent thrombosis vs UFH when full-dose post-PCI infusion used for 2–4h 🟡 Enoxaparin IV — Class 2b alternative 🚫 Fondaparinux — do NOT use to support PCI (catheter thrombosis risk) #Bivalirudin#BRIGHT4 ❤️ Multivessel CAD in STEMI — major update! ⚡ 🟥 Complete revascularization recommended in hemodynamically stable STEMI MVD (Class 1, LOE A) 🟡 Single-procedure multivessel PCI may be preferred over staged (Class 2b, LOE B-R) — BIOVASC MULTISTARS AMI 🚫 Cardiogenic shock → culprit-only PCI only (Class 3: Harm) — CULPRITSHOCK #CompleteRevascularization#MVD 😮 Cardiac arrest STEMI 🟥 Resuscitated awake STEMI → PPCI (Class 1, LOE B-NR) 🟡 Comatose  favorable features STEMI → PPCI reasonable (Class 2b) 🚫 Comatose hemodynamically stable  NO ST-elevation → immediate angiography NOT recommended (Class 3: No Benefit, LOE A) — consistent across 6 RCTs #CardiacArrest#PostROSC ⚡️  Cardiogenic shock — new MCS guidance 🟡 Microaxial flow pump (Impella) in selected STEMI severe/refractory shock → reasonable to reduce death (Class 2a, LOE B-R) — DanGer-SHOCK: ↓ 26% all-cause mortality at 180d (NNT=8) ⚠️ But: ↑ bleeding, limb ischemia, renal failure. Patient selection matters. 🚫 Routine IABP or VA-ECMO → not recommended (Class 3: No Benefit) #CardiogenicShock#DanGerSHOCK#MCS 💊 Secondary prevention post-STEMI 🟥 [Class 1](LOE A) ✅️ High-intensity statin for ALL — consider adding ezetimibe upfront ✅️ Add nonstatin agent if LDL-C ≥70 mg/dL on max statin ✅️ DAPT ≥12 months if no high bleeding risk ✅️ Annual influenza vaccine ✅️ Cardiac rehab referral before discharge #SecondaryPrevention#StatinTherapy 🏁 STEMI 2025 — the takeaways: 1️⃣ Radial access is now Class 1 standard 2️⃣ Bivalirudin upgraded to Class 1 for PPCI 3️⃣ Complete revascularization: single-procedure preferred over staged 4️⃣ Microaxial pump: benefit shown but complications high — select carefully 5️⃣ Immediate angiography after non-STEMI arrest: still a firm Class 3 📄 Rao SV et al. Circulation 2025;151:e771–e862≤90min FMC-device26%↓ mortality (MCS)NNT 8DanGer-SHOCK#STEMI#CardioTwitter#ACSGuidelines2025