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NICE

NICE NG185 2020: acute coronary syndrome management guidelines

NICE NG185 covers the diagnosis and management of acute coronary syndromes including STEMI, NSTEMI and unstable angina in adults. It emphasises timely risk stratification, appropriate use of antiplatelet and antithrombotic therapy, decisions about coronary reperfusion or revascularisation strategy, and the need for cardiac rehabilitation and secondary prevention after the acute event.

NICE2020 editionSummary
Official guidelineAcute coronary syndromes (NG185). NICE, 2020.
Read the official guideline · Checked for a newer edition on 2026-10-20
We do not reproduce the guideline text — this page is an independent summary.

Who it applies to

Adults presenting with suspected or confirmed acute coronary syndrome in prehospital, emergency department, and inpatient cardiology settings.

Key recommendations

  • Offer a 12-lead ECG as soon as possible after initial assessment to identify ST-elevation MI and guide urgent reperfusion decisions.
  • In suspected STEMI, arrange immediate transfer for primary percutaneous coronary intervention if it can be delivered within the recommended time window from diagnosis.
  • Use a validated risk assessment tool (such as GRACE) to estimate mortality risk in NSTEMI/unstable angina and guide timing of angiography.
  • Offer dual antiplatelet therapy (aspirin plus a second antiplatelet agent) to patients with confirmed ACS unless contraindicated by high bleeding risk.
  • Consider an antithrombin agent such as fondaparinux in NSTEMI/unstable angina patients not at high bleeding risk who are not going for immediate angiography.
  • Offer coronary angiography, with follow-on PCI if indicated, to intermediate and higher risk NSTEMI patients within a timeframe based on their risk category.
  • Do not routinely offer glycoprotein IIb/IIIa inhibitors unless as part of a planned PCI strategy in selected higher-risk patients.
  • Start all patients with confirmed ACS on secondary prevention medication (statin, ACE inhibitor, beta-blocker) as appropriate, taking into account comorbidities and tolerability.
  • Offer a comprehensive cardiac rehabilitation programme to all patients after an acute coronary event, addressing lifestyle, psychological and educational needs.
  • Provide patients with information about their diagnosis, treatment, and long-term outlook, including return to work, driving, and sexual activity.

Practice points for students

  • Troponin testing alone does not define the ACS subtype; ECG findings determine whether STEMI pathway (immediate reperfusion) applies.
  • GRACE score risk category determines timing of invasive angiography in NSTEMI, not just presence of ischaemia.
  • Dual antiplatelet therapy duration and choice of second agent depend on bleeding risk and revascularisation strategy.
  • Cardiac rehabilitation should begin as an offer to every ACS patient, not reserved for those who ask.
  • Secondary prevention drug initiation should start during the inpatient stay rather than being deferred to primary care.

Condition

Acute coronary syndrome

Other guidelines on this topic

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by NICE. It is not medical advice: always read the original guideline before applying it to patients.