Intended for healthcare professionals

Practice Guidelines

Acute coronary syndromes: summary of updated NICE guidance

BMJ 2021; 372 doi: (Published 15 January 2021) Cite this as: BMJ 2021;372:m4760
  1. Simon J Corbett, consultant cardiologist1,
  2. Saoussen Ftouh, senior research fellow2,
  3. Sedina Lewis, senior research fellow2,
  4. Kate Lovibond, health economics lead2
  5. on behalf of the Guideline Committee
  1. 1University Hospital Southampton NHS Foundation Trust, Southampton, UK
  2. 2National Guideline Centre, Royal College of Physicians, London, UK
  1. Correspondence to S Corbett simon.corbett{at}

What you need to know

  • Prasugrel is recommended as dual anti-platelet therapy in combination with aspirin for people with ST-elevation myocardial infarction being treated with primary percutaneous coronary intervention (PCI)

  • Prasugrel or ticagrelor are recommended as dual anti-platelet therapy in combination with aspirin for people with non-ST-elevation myocardial infarction or unstable angina being treated with PCI

  • In people with acute coronary syndromes treated with PCI, who have a separate indication for oral anticoagulation (eg, atrial fibrillation), use clopidogrel and oral anticoagulant for up to one year. Do not use prasugrel or ticagrelor, and avoid long-term addition of aspirin

Acute coronary syndromes (ACS), comprising ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina, are an important cause of morbidity and mortality in the UK and worldwide.1 The National Institute for Health and Care Excellence (NICE) previously published four guidelines to improve care for people in the UK who have had an ACS.2345 In 2018, NICE identified eight key areas of clinical practice across all aspects of existing ACS guidelines that should be reviewed for update on the basis of new evidence and stakeholder feedback (box 1).

Box 1

Clinical areas updated in the NICE guideline on acute coronary syndromes (NG185)

  • Early invasive management in unstable angina/NSTEMI

  • Anti-platelet therapy in adults with ACS

  • Anti-thrombin therapy in adults with unstable angina/NSTEMI who are being considered for coronary angiography within 24 hours of admission

  • Anti-thrombin therapy in adults with STEMI intended for primary PCI

  • Culprit vessel-only versus complete revascularisation in adults with STEMI undergoing primary PCI

  • Drug-eluting stents in adults with ACS

  • Anti-platelet and anticoagulant therapies for people who have had an ACS and a separate indication for anticoagulation

  • Duration of β-blocker therapy after myocardial infarction in adults without left ventricular dysfunction


Rather than individually updating the four existing ACS guidelines, all four guidelines have been incorporated into one overarching updated guideline covering all aspects …

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