🗞 Rapid Fire: Guideline Summaries
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You’ll find some of the newest guidelines relevant to Primary Care below, along with a few key takeaways from each one of them.
Some of these guidelines are dense – but don’t worry, over at Pathway, they’re all neatly summarized and broken down into digestible chunks to make them easier to understand.
❤️ NSTEMI - from the American College of Cardiology (ACC/AHA/ACEP/NAEMSP/SCAI 2025), the American Academy of Family Physicians (AAFP 2024), and the American College of Chest Physicians (ACCP 2024), among others: -
Refer patients presenting with acute chest pain and high suspicion of ACS to the emergency department and use predictive risk scores there to aid in the prognosis, diagnosis, and management. (B)
- Obtain and interpret a 12-lead ECG within 10 minutes of first medical contact in patients with suspected ACS to guide management. (B)
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Obtain serial 12-lead ECGs to detect potential ischemic changes in patients with suspected ACS when the initial ECG is nondiagnostic, particularly if clinical suspicion of ACS is high, symptoms persist, or the clinical condition deteriorates. (B)
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Obtain cardiac troponin as soon as possible in patients with suspected ACS, preferably using a high-sensitivity cardiac troponin assay. (B)
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Obtain repeat measurements in patients with suspected ACS with an initial nondiagnostic high-sensitivity cardiac troponin or cardiac troponin at 1-2 hours for high-sensitivity cardiac troponin and 3-6 hours for conventional cardiac troponin after the initial sample collection. (B)
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Consider performing angiography before hospital discharge to reduce major adverse cardiovascular events in patients with non-ST-elevation ACS who are not at high risk and are intended for an invasive strategy. (C)
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Administer supplemental oxygen in patients with ACS and confirmed hypoxia (oxygen saturation < 90%) to increase oxygen saturations to ≥ 90% in order to improve myocardial oxygen supply and decrease anginal symptoms. (B)
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Initiate oral β-blocker therapy early (< 24 hours) in patients with ACS without contraindications to reduce the risk of reinfarction and ventricular arrhythmias. (A)
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Initiate an oral ACEI or an ARB in high-risk patients with ACS (LVEF ≤ 40%, hypertension, or diabetes mellitus) to reduce all-cause death and major adverse cardiovascular events. (A)
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Initiate a mineralocorticoid receptor antagonist in patients with ACS and LVEF ≤ 40%, with HF symptoms and/or diabetes mellitus, to reduce all-cause death and major adverse cardiovascular events. (B)
- Consider initiating low-dose colchicine in patients after ACS to reduce the risk of major adverse cardiovascular events. (C)
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Common medications in ACS
🩸 Microhematuria - from the American Urological Association (AUA/SUFU 2025), the American College of Radiology (ACR 2020), and the American College of Obstetricians and Gynecologists (ACOG/AUGS 2017): -
Elicit a history and perform a physical examination, including BP measurement, and obtain serum creatinine in patients with microscopic hematuria to assess risk factors for genitourinary malignancy (such as detailed smoking history), medical renal disease, gynecologic, and non-malignant genitourinary causes of microscopic hematuria. (B)
- Obtain cystoscopy and renal ultrasound in patients with microscopic hematuria categorized as intermediate risk for malignancy. (B)
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Consider offering urine cytology or validated urine-based tumor markers to intermediate-risk patients who have been appropriately counseled and who wish to avoid cystoscopy and accept the risk of forgoing direct visual inspection of the bladder urothelium. Obtain renal and bladder ultrasound in these cases. (C)
- Engage in shared decision-making regarding whether to repeat urinalysis in the future in patients with a negative risk-based hematuria evaluation. (B)
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Obtain repeat urinalysis within 6 months in low/negligible-risk patients with microscopic hematuria rather than perform immediate cystoscopy or imaging. (B)
🦀 Hepatocellular Carcinoma - from the European Society of Medical Oncology (ESMO 2025), the European Association for the Study of the Liver (EASL 2025), and the American Society of Clinical Oncology (ASCO 2024), among others:
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Obtain surveillance for HCC in patients with cirrhosis unless they have a relatively high risk of death from non-HCC causes or cannot be offered a curative-intent treatment for HCC, such as patients with Child-Pugh class C cirrhosis ineligible for liver transplantation. (B)
- Obtain screening for HCC in all patients with cirrhosis, irrespective of its etiology, if liver function and comorbidities allow tumor treatment. (B)
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Obtain screening for HCC in patients with chronic HBV infection and a moderate or high HCC risk score (such as PAGE-B) at the onset of nucleoside analog therapy. (B)
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Obtain liver ultrasound every 6 months for screening of HCC. Consider combining ultrasound with α-fetoprotein to increase sensitivity while decreasing specificity as a reasonable option. Insufficient evidence to support the use of other imaging modalities, such as abbreviated magnetic resonance or serum biomarkers. (B)
- Use the BCLC staging system for tumor staging and prognostic purposes. (A)
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Obtain α-fetoprotein once a definitive diagnosis of HCC has been made to provide prognostic information. (B)
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Advise weight loss in patients with obesity, alcohol cessation, and tobacco cessation to reduce the risk of liver-related and other adverse outcomes, and to potentially lower the risk of HCC. (B)
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Consider advising coffee consumption to reduce the risk of HCC. (C)
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Initiate treatment with nucleoside or nucleotide analogs in patients with HBV infection to reduce the risk of developing HCC, both de novo and recurrence, following appropriate treatment protocols. (B)
❤️🩹 STEMI - from the Society for Cardiovascular Angiography and Interventions (SCAI/NAEMSP/AHA/ACC/ACEP 2025), the American Academy of Family Physicians (AAFP 2024), and the American College of Chest Physicians (ACCP 2024), among others:
- Obtain and interpret a 12-lead ECG within 10 minutes of first medical contact in patients with suspected ACS to identify patients with STEMI and guide management. (B)
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Obtain a lipid profile in all patients with STEMI as soon as possible after presentation. (B)
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Arrange immediate emergency medical services transport for patients with suspected STEMI to a PCI-capable hospital for primary PCI, aiming for a first medical contact to a first-device time of ≤ 90 minutes. (B)
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Administer fibrinolytic therapy in patients with STEMI and symptom onset of < 12 hours, with an anticipated delay to primary PCI ≥ 120 minutes from first medical contact, in the absence of contraindications, to reduce major adverse cardiovascular events. (A)
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Administer an initial oral loading dose of aspirin, followed by daily low-dose aspirin, in patients with ACS to reduce death and major adverse cardiovascular events. (A)
- Do not administer glycoprotein IIb/IIIa inhibitors routinely in patients with ACS due to lack of ischemic benefit and increased risk of bleeding. (D)
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Discontinue aspirin after 1-4 weeks of triple antithrombotic therapy in patients with ACS requiring OAC therapy, with continued use of a P2Y12 inhibitor, preferably clopidogrel, and an OAC to reduce bleeding risk. (B)
- Refer patients with ACS to an outpatient cardiac rehabilitation program prior to hospital discharge to reduce death, myocardial infarction, and hospital readmissions, and improve functional status and QoL. (A)
🍟 Hypertriglyceridemia - from the American Association of Clinical Endocrinologists (AACE 2025), the Endocrine Society (ES 2020), and the European Society of Cardiology (ESC/EAS 2020), among others:
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Consider adding eicosapentaenoic acid (icosapent ethyl) to statins in patients with hypertriglyceridemia (150-499 mg/dL) with CVD or at high risk of ASCVD. (C)
- Avoid using niacin in addition to usual care in patients with hypertriglyceridemia (150-499 mg/dL) with or at high risk of ASCVD. (D)
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Initiate pharmacologic treatment as an adjunct to dietary modifications and exercise to prevent pancreatitis in adult patients with fasting triglyceride levels > 500 mg/dL (5.6 mmol/L). (B)
- initiate statins as first-line therapy to reduce cardiovascular risk in high-risk patients with hypertriglyceridemia (triglyceride levels > 2.3 mmol/L; > 200 mg/dL). (B)
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Consider adding fenofibrate or bezafibrate to statins for primary prevention in patients with triglyceride levels of > 2.3 mmol/L (> 200 mg/dL) achieved LDL-C goal. (C)
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Lipid-lowering medications
Acknowledgments: - Editorial Team: Jeremy Swisher, MD, Cole Phillips, MD, Khudhur Moh, MD, Hovhannes Karapetyan, MD
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