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This state-of-the-art review synthesizes advances from 2023–2025 across diagnosis, revascularization, antithrombotic therapy, and secondary prevention, highlighting high-sensitivity troponin algorithms, GRACE 3.0 calibration, and imaging-informed PCI strategies. It also reviews complete versus culprit-only approaches, risk-stratified DAPT duration and aspirin use, and early intensive LDL-cholesterol reduction. Implementation covers sex- and age-aware tailoring, bleeding-risk mitigation, digitally enabled rehabilitation, and registry-driven quality improvement, translating evidence into bedside decision algorithms.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/acute-coronary-syndromes-state-of-the-art-diagnosis-management-and-secondary-prevention/461607/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/acute-coronary-syndromes-state-of-the-art-diagnosis-management-and-secondary-prevention/461607.png","ImageObject",300,407,{"name":92,"@type":93},"nayy☆","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-08","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":39},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What diagnostic advances underpin contemporary ACS pathways in this review?","Question",{"text":112,"@type":113},"High-sensitivity troponin-based accelerated pathways remain foundational. GRACE 3.0 improves calibration for early versus delayed angiography, and selective CCTA plus intracoronary imaging/physiology support mechanism-focused PCI planning.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How does the review describe current approaches to revascularization?",{"text":117,"@type":113},"Complete revascularization is emphasized for multivessel disease. Recent data favor culprit-only PCI acutely and staged non-culprit treatment during the index stay in most STEMI presentations, especially when heart-failure physiology is present.",{"name":119,"@type":110,"acceptedAnswer":120},"What changes are highlighted for antithrombotic therapy and secondary prevention?",{"text":121,"@type":113},"Aspirin remains critical early after ACS-PCI, while emerging evidence supports shorter DAPT and aspirin withdrawal after 1 month in carefully selected low-ischaemic-risk patients, and questions remain about day-0 aspirin-free strategies in unselected ACS. 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Nienaber 1, *  \nAcademic Editor: Nicola Cosentino  \nReceived: 12 November 2025  \nRevised: 15 December 2025  \nAccepted: 16 December 2025  \nPublished: 19 December 2025  \nCopyright: © 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license.  \n1 Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Trust Foundation, London SW3 6NP, UK; [xun.yuan@nhs.net](xun.yuan@nhs.net) (X.Y.)  \n2 Department of Cardiology, Milton Keynes University Hospital, Milton Keynes MK6 5LD, UK  \n3 Department of Cardiology, Heart Centre Cologne, Faculty of Medicine and University Hospital, University of Cologne, 50937 Cologne, Germany  \n4 Department of Cardiology, University Hospital Heidelberg-Campus Mannheim, 69120 Mannheim, Germany  \n* Correspondence: [christophantontheodor.nienaber@nhs.net](christophantontheodor.nienaber@nhs.net)  \nAbstract  \nBackground: Acute coronary syndromes (ACSs) remain a leading cause of death and disability. Since the publication of the 2023 ESC ACS guidelines, multiple studies and an ESC/EAS dyslipidaemia update have refined how clinicians diagnose, revascularize, and treat ACS across the care continuum. Content: This state-of-the-art review synthesizes advances from 2023 to 2025 across five domains. Diagnosis: High-sensitivity troponin-based accelerated pathways remain foundational; GRACE 3.0 improves calibration for early vs. delayed angiography, while selective use of CCTA and routine use of intracoronary imaging/physiology help define the mechanism and optimize PCI. Revascularization: complete revascularization continues to underpin care in multivessel disease, with recent data favouring culprit-only PCI acutely and staged non-culprit treatment during the index stay in most STEMI presentations, particularly with heart-failure physiology. Antithrombotic therapy: Aspirin remains critical early after ACS-PCI; emerging evidence supports shorter DAPT and aspirin withdrawal after 1 month in carefully selected, low-ischaemic-risk patients, whereas day-0 aspirin-free strategies in unselected ACS are not non-inferior. Secondary prevention: A “strike early and strong” approach to LDL-cholesterol—often with combination therapy in hospital—is emphasized, alongside nuanced roles for SGLT2 inhibitors and GLP- 1 receptor agonists. Special populations and implementation: Sex-and age-aware tailoring (including MINOCA/SCAD evaluation), pragmatic bleeding-risk mitigation, digitally enabled cardiac rehabilitation, and registry-driven quality improvement translate evidence into practice. Summary: Contemporary ACS care is moving from uniform protocols toward risk-stratified, mechanism-informed pathways. We offer practical algorithms and checklists to align interventional timing, antithrombotic intensity/duration, and secondary prevention with individual patient risk—bridging new evidence to bedside decisions.  \nKeywords: acute coronary syndrome; myocardial infarction; dual antiplatelet therapy; PCI; cardiogenic shock; dyslipidaemia; precision medicine  \n1. Introduction  \nAcute coronary syndromes (ACSs) remain a leading global health challenge, with enormous clinical and societal impact. Cardiovascular disease is still a primary cause of death, accounting for nearly 17.9 million deaths annually worldwide with acute coronary events comprising a significant proportion of this burden [1] . For example, in the United  \nStates alone, over 1.2 million people are hospitalized with an ACS per year [2] . Beyond mortality, ACS leads to substantial morbidity and healthcare costs, underscoring the importance of continually improving management strategies to reduce its toll [3] .  \nIn the attempts to standardize ","cbCaidMxIo93CCRH","https://ap.wps.com/l/cbCaidMxIo93CCRH","pdf",2290096,26,"English","# Abstract\n## Background\n## Content\n## Summary\n# Keywords\n# Introduction\n## Global burden and impact\n## 2023 ESC ACS Guidelines and spectrum coverage\n## Evidence evolution in 2025\n## Key trial themes","[{\"question\":\"What diagnostic advances underpin contemporary ACS pathways in this review?\",\"answer\":\"High-sensitivity troponin-based accelerated pathways remain foundational. GRACE 3.0 improves calibration for early versus delayed angiography, and selective CCTA plus intracoronary imaging/physiology support mechanism-focused PCI planning.\"},{\"question\":\"How does the review describe current approaches to revascularization?\",\"answer\":\"Complete revascularization is emphasized for multivessel disease. Recent data favor culprit-only PCI acutely and staged non-culprit treatment during the index stay in most STEMI presentations, especially when heart-failure physiology is present.\"},{\"question\":\"What changes are highlighted for antithrombotic therapy and secondary prevention?\",\"answer\":\"Aspirin remains critical early after ACS-PCI, while emerging evidence supports shorter DAPT and aspirin withdrawal after 1 month in carefully selected low-ischaemic-risk patients, and questions remain about day-0 aspirin-free strategies in unselected ACS. For secondary prevention, the review stresses early, strong LDL-cholesterol lowering (often with combination therapy in-hospital) and discusses nuanced roles for SGLT2 inhibitors and GLP-1 receptor agonists.\"}]","Acute Coronary Syndromes: State-of-the-Art Diagnosis, Management, and Secondary Prevention | PDF",1790761959,66]