What are the AHA/ACC guidelines on initial hospital care for acute coronary syndrome (ACS)?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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The 2014 AHA/ACC recommendations for initial hospital care are summarized below. [112]


Administer supplemental oxygen only when the oxygen saturation falls below 90%, respiratory distress is present, or other high-risk features for hypoxemia are present. (Class I; level of evidence C) 


Administer sublingual nitroglycerin (NTG) every 5 minutes up to 3 times for continuing ischemic pain, and then assess the need for intravenous (IV) NTG. (Class I; level of evidence: C) 

Administer IV NTG for persistent ischemia, heart failure (HF), or hypertension. (Class I; level of evidence: B) 

Nitrates are contraindicated with recent use of a phosphodiesterase inhibitor. (Class III; level of evidence: B)  


IV morphine sulfate may be reasonable for continued ischemic chest pain despite maximally tolerated anti-ischemic medications. (Class IIb; level of evidence: B)  

Nonsteroidal anti-inflammatories (NSAIDs) (except aspirin) should not be initiated and should be discontinued because of the increased risk of major adverse cardiac events (MACE) associated with their use. (Class III; level of evidence: B)  

Beta-adrenergic blockers

Initiate oral beta blockers in the absence of HF, low-output state, risk for cardiogenic shock, or other contraindications to beta blockade. (Class I; level of evidence: A)  

Use sustained-release metoprolol succinate, carvedilol, or bisoprolol for beta-blocker therapy in patients with concomitant NSTE-ACS, stabilized HF, and reduced systolic function (Class I; level of evidence: C)  

Re-evaluate to determine subsequent eligibility in patients with initial contraindications to beta blockers. (Class I; level of evidence: C)

It is reasonable to continue beta-blocker therapy in patients with normal LV function with NSTE-ACS. (Class IIa; level of evidence: C)

IV beta blockers are potentially harmful when risk factors for shock are present. (Class III; level of evidence: B)

Calcium channel blockers (CCBs)

Administer initial therapy with nondihydropyridine CCBs in patients with recurrent ischemia and contraindications to beta blockers in the absence of LV dysfunction, increased risk for cardiogenic shock, PR interval longer than 0.24 s, or second- or third-degree atrioventricular block without a cardiac pacemaker. (Class I; level of evidence: B)

Administer oral nondihydropyridine calcium antagonists in patients with recurrent ischemia after use of beta blockers and nitrates in the absence of contraindications. (Class I; level of evidence: C) 

CCBs are recommended for ischemic symptoms when beta blockers are not successful, are contraindicated, or cause unacceptable side effects. (Class I; level of evidence: C) 

Long-acting CCBs and nitrates are recommended for patients with coronary artery spasm. (Class I; level of evidence: C) 

Immediate-release nifedipine is contraindicated in patients with NSTE-ACS in the the absence of a beta blocker therapy (Class III; level of evidence: B) 

Cholesterol management

Initiate or continue high-intensity statin therapy in patients with no contraindications. (Class I; level of evidence: A) 

Obtain a fasting lipid profile in patients with NSTE-ACS, preferably within 24 hours of presentation. (Class IIa; level of evidence:C) 

Angiotensin-converting enzyme (ACE) inhibitors

Class I

ACE inhibitors should be started and continued indefinitely in all patients with a left ventricular ejection fraction (LVEF) below 40% and in those with hypertension, diabetes mellitus, or stable chronic kidney disease (CKD), unless contraindicated. (Level of evidence: A)

Use angiotensin receptor blockers (ARBs) in patients with heart failure or MI with an LVEF below 40% who are ACE inhibitor intolerant. (Level of evidence: A)

Use aldosterone blockade in post–MI patients who are without significant renal dysfunction or hyperkalemia who are receiving therapeutic doses of ACE inhibitor and beta blockers and have an LVEF below 40%, diabetes mellitus, or heart failure. (Level of evidence: A)

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