Focused Update on Randomized Trials in Acute Coronary Syndromes: A Scoping Review

Background and Aim: Evidence-based medicine is dynamic. We appraised recent evidence on the management of acute coronary syndromes (ACS). Methods: A PRISMA scoping review of randomized controlled trials (RCTs) published in PubMed/MEDLINE between January 2025 and March 2026 was conducted. Only trials involving ≥ 500 ACS patient-years and reporting total or cardiovascular death, myocardial infarction, stroke and clinically relevant safety events were included. Comorbid atrial fibrillation and shock were excluded. Data extraction was prespecified. Results: Ten RCTs on antiplatelet therapy, percutaneous coronary intervention (PCI) and beta-blocker treatment were retained and analyzed for bias. Within the limits of each trial, the following messages emerge. After ACS-PCI, very early (day 4) antiplatelet monotherapy may not provide adequate anti-ischemic protection compared to 12-month dual antiplatelet therapy (DAPT; NEO-MINDSET trial). In ACS-PCI patients at low ischemic risk, 1-month DAPT followed by P2Y12 inhibitor alone can reduce major or clinically relevant nonmajor bleeding compared to 12-month DAPT, without apparent loss of anti-ischemic protection (TARGET-FIRST and 4D-ACS trials). For ACS patients receiving 12-month DAPT, ischemic and bleeding outcomes seem not to differ significantly when aspirin is given once or twice daily (ANDAMAN trial), nor when DAPT is clopidogrel-based or ticagrelor-based within specific populations (Canadian Bayesian pragmatic TC4 trial). In ACS patients undergoing coronary bypass, 12-month ticagrelor-based DAPT compared to aspirin alone enhances major bleeding risk without apparent anti-ischemic benefit (TACSI trial). Complete versus culprit-only revascularization leads to lower 3-year rates of ischemic events in older ACS patients with multivessel disease across renal function strata (FIRE trial). For ACS patients with multivessel disease, immediate complete revascularization failed to reach non-inferiority compared to pre-discharge complete revascularization (OPTION-STEMI trial). For patients with a left ventricular ejection fraction above or equal to 40% after myocardial infarction, beta-blocker treatment compared to none, over a follow-up ≥ 3.5 years, improved outcomes in BETAMI-DANBLOCK but not in REBOOT-CNIC. Conclusions: The data retained by this scoping review have implications that impact common clinical-practice decisions.