Evidence gap
The answer is roughly known; the field just hasn't synchronized practice.
Resolves via: Guideline update + dissemination
How cardiologists read the fine print of one guideline decides whether millions of heart attack patients get a year of dual antiplatelet therapy or an early de-escalation — and which P2Y12 drug they walk out on.
Active since Jan 2025
The debate
11 clinicians quoted on the record
The guideline carries competing Class 1 recommendations — a full year of dual antiplatelet therapy to cut ischemic events alongside shortening or de-escalating it to cut bleeding — and clinicians can't apply both, so the document needs clarification before it drives practice.
“The 2025 ACC/AHA ACS guidelines remain an area that's still controversial.”
“The 2025 ACC/AHA ACS guidelines remain an area that's still controversial.”
+ 3 more on this side
Merging STEMI and NSTEMI into one framework finally aligns practice with a decade of trials, and the flexibility clinicians read as 'conflict' is really room to individualize between ischemic and bleeding risk.
“unclear”
“By grouping STEMI and NSTEMI together, she added, “I’m really hoping that it’s going to make everybody much more comfortable because we had clinical trials that came out, but the guidelines were so out of date.””
+ 1 more on this side
Where the experts land
5–3 on record · 3 unplaced
Fix the conflicts first · 5
On the record, unplaced · 3
Unified guideline is progress · 3
“some recommendations may benefit from clarification to improve internal alignment. For example, the guideline includes Class 1 recommendations both for DAPT for 1 year (to reduce ischemic events) and for switching to ticagrelor monotherapy after 1 month of tolerating DAPT (to red”
Where the field stands
Common ground
Unstable late presenters need the cath lab, and stable patients well beyond 48 hours do not need routine stenting.
The crux
Whether a stable STEMI patient arriving 24 to 48 hours after symptoms should still be taken for stenting.
Still unknown
A contemporary randomized trial in that 24-to-48-hour window, measuring death and heart failure, would settle it.
On the record
Their own words — position stated as published
flag internal Class 1 tension
“For example, the guideline includes Class 1 recommendations both for DAPT for 1 year (to reduce ischemic events) and for switching to ticagrelor monotherapy after 1 month of tolerating DAPT (to reduce bleeding).”
unclear · JACC ACS antithrombotic commentary authors · 2 statements · JACC ↗
complete revascularization
“A strategy of complete revascularization is recommended in patients with ST-segment elevation myocardial infarction or non–ST-segment elevation ACS.”
Rao SV · Guideline writing committee chair · AHA Journals ↗
caution outside proven shock criteria
“The current guidelines rightly -- American and European -- remain cautious with the class 2b recommendations, reflecting a field where clinical enthusiasm has clearly outpaced high quality evidence.”
Roxana Mehran · Mount Sinai; ACC discussant · MedPage Today ↗
Where do you land?
No votes yet — the measured split appears at 10.
Where the evidence stands
2025 ACC/AHA ACS guideline kept/upgraded early (<24 h) oral beta-blockade to Class 1, LOE A. A JACC critique argues that recommendation rests on old RCTs, conflicts with contemporary post-MI de-prescribing trials, and should be 2b or retired pending REBOOT/BETAMI-era data. Unknowns: acute arrhythmia prevention versus long-term remodeling, and STEMI vs NSTEMI.
What's settled
4What's still open
4How this gets settled
The answer is roughly known; the field just hasn't synchronized practice.
Who could settle it
Know an expert who could settle this? Suggest one →
Sources & verification
+ 31 more, each dated and verification-tagged
Who we found publicly on the record — a snapshot, not a poll of the field. Larger dots are deciders; dashed dots are scan-reported, not yet verified.