ACLS 2025 Part 11: Post–Cardiac Arrest Care:

2026-05-31

心肺復甦之後的照護. TTM

之前的TTM是 target temperature control. 現在 TTM 是 total temperature control. 

目前建議在 ROCS 之後維持體溫 32-37.5 至少 36 小時. 

Part 11: Post–Cardiac Arrest Care: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

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The optimal overall duration of temperature control, including hypothermic temperature control (32 °C–34 °C) and normothermic or fever-prevention temperature control (36 °C–37.5 °C), is an important area of ongoing investigation. In one randomized trial, there was no difference in outcomes comparing hypothermic temperature control for 24 versus 48 hours, although the trial may have been underpowered and effect estimates favored longer temperature control durations.10 In another recent randomized trial, there was no difference in outcomes comparing a period of device-based fever prevention of 12 versus 48 hours after an initial 24-hour period of temperature control to 36 °C (ie, 36 versus 72 total hours of temperature control, respectively).15 The 2 large TTM randomized trials protocolized patients to 72 hours of total temperature control.6,9 Recognizing evolution of evidence and definitions with respect to temperature control, 36 hours of total temperature control is the shortest recommended duration. Multiple observational studies have found strong associations between post–cardiac arrest fever and poor outcomes, including for fevers occurring after an initial 24-hour period of temperature control.16–19 Results of the ICECAP (Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients) trial, which aimed to identify the optimal duration of hypothermic temperature control for patients with both shockable and nonshockable rhythms, are pending after the study was stopped in June 2025.20

Top 10 Take-Home Messages for Adult Advanced Cardiovascular Life Support

1.

The section on neuroprognostication was updated to include predictors of favorable outcome, and neurofilament light chain (NfL) was added as a serum biomarker: When performed in combination with other prognostic tests, it may be reasonable to consider high serum values of neuron-specific enolase (NSE) or NfL within 72 hours after cardiac arrest to support the prognosis of unfavorable neurological outcome in patients who remain comatose.

2.

It is reasonable that temperature control be maintained for at least 36 hours in adult patients who remain unresponsive to verbal commands after return of spontaneous circulation (ROSC).

3.

It may be reasonable to perform computed tomography (CT) for adult patients after ROSC to investigate the etiology of cardiac arrest and complications from resuscitation, and it may be reasonable to perform echocardiography or point-of-care cardiac ultrasound for adult patients after ROSC to identify clinically significant diagnoses requiring intervention.

4.

Coronary angiography is recommended prior to hospital discharge in adult cardiac arrest survivors with suspected cardiac etiology, particularly in the presence of an initial shockable rhythm, unexplained left ventricular systolic dysfunction, or evidence of severe myocardial ischemia.

5.

Hypotension should be avoided in adults after ROSC by maintaining a minimum mean arterial pressure (MAP) of at least 65 mm Hg, though there is insufficient evidence to recommend a specific vasopressor to treat low blood pressure in adult patients after cardiac arrest.

6.

In adult patients with cardiogenic shock (CS) after cardiac arrest and ROSC, temporary mechanical circulatory support (MCS) should not be routinely used, though in highly selected adult patients with refractory CS after cardiac arrest and ROSC, temporary MCS may be considered.

7.

A new section dedicated to diagnosis and management of myoclonus after cardiac arrest was developed and includes the following: Treatment to suppress myoclonus without an electroencephalography (EEG) correlate is not recommended in adult survivors of cardiac arrest.

8.

A therapeutic trial of a nonsedating antiseizure medication may be reasonable in adult patients who do not follow commands after ROSC with EEG patterns on the ictal-interictal continuum.

9.

It is recommended that cardiac arrest survivors and their caregivers have structured assessment and treatment/referral for emotional distress after medical stabilization and before hospital discharge.

10.

Interventions to address health care professional burnout may be beneficial.

ACLS 2025 指引-急性冠心症標準治療 Standard Medical Therapies for STEMI and NSTE-ACS

2026-05-30

 
2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

 僅節錄標準治療這一段

4.1 氧氣維持90%即可. 過多氧氣並不會減少一年內死亡率. 

4. Standard Medical Therapies for STEMI and NSTE-ACS

4.1. Oxygen Therapy
4.2. Analgesics 止痛

Synopsis 概要 

止痛藥物可改善症狀但並不能改善ACS急性冠心症預後. (改善症狀也是很重要一再被強調的)

通常是使用 Nitrates 硝酸鹽類及鴉片類 opiate 藥物 

若硝酸鹽類無法緩解疼痛症狀. 應盡快將冠狀動脈打通. 而不是只給鴉片類止痛藥物壓住症狀

避免使用NSAIS(除了 aspirin 之外). 因為會增加MACE. 不建議常規使用

Table 6. Analgesic Treatment Options for Cardiac Chest Pain

Medication	Route	Suggested Dosing	Considerations
Nitroglycerin*	SL (tablets, spray)	0.3 or 0.4 mg every 5 min as needed up to a total of 3 doses	Use in hemodynamically stable patients with SBP ≥90 mm Hg.
Nitroglycerin*	IV	Start at 10 μg/min and titrate to pain relief and hemodynamic tolerability.	Consider for persistent anginal pain after oral nitrate therapy, or if ACS is accompanied by hypertension or pulmonary edema.20–22 Avoid use in suspected RV infarction, SBP <90 mm Hg or a change in SBP >30 mm Hg below baseline. Tachyphylaxis may occur after approximately 24 h.
Morphine	IV	2-4 mg; may repeat if needed every 5-15 min. Doses up to 10 mg may be considered.	Use for relief of pain that is resistant to other maximally tolerated anti-ischemic medications. May delay the effects of oral P2Y12 therapy.7,9–12 Monitor closely for adverse effects.
Fentanyl	IV	25-50 μg; may repeat if needed. Doses up to 100 μg may be considered.	Use for relief of pain that is resistant to other maximally tolerated anti-ischemic medications. May delay the effects of oral P2Y12 therapy.8 Monitor closely for adverse effects.

Patients presenting with known or suspected ACS often experience chest pain or other uncomfortable symptoms. Rapid and effective pain relief remains an important treatment goal to prevent sympathetic activation and adverse clinical sequelae (Table 6). Analgesic therapies may provide symptomatic relief, but they have not been shown to improve clinical outcomes in patients with ACS.1,2 Nitrates and opiate medications remain effective treatment options for management of pain in ACS but should be thoughtfully utilized to prevent potential harm.3–6 In particular, rapid coronary revascularization should be pursued for patients with ongoing ischemic symptoms that are not relieved with nitrates, and opiates should not be used solely to mask these symptoms. Concerns have also been raised that the use of opiates may delay gastric and intestinal absorption of orally administered P2Y12 inhibitors, thereby delaying their pharmacodynamic effects in patients undergoing PCI.7–10 However, the clinical relevance of these pharmacodynamic findings remains disputed.11–14 Use of nonaspirin nonsteroidal anti-inflammatory drugs should be avoided for management of suspected or known ischemia pain whenever possible.15–17 Use of nonsteroidal anti-inflammatory drugs is associated with increased risk of MACE in patients with and without prior cardiac disease, with no documented benefit to support routine use in patients with ACS.15–19

4.3. Antiplatelet Therapy
4.3.1. Aspirin

概要 Synopsis

Aspirin 可降低MI後的血管性死亡機率
aspirin 通常建議終身服用. 但在心肌梗塞一至三個月後可慎選個案. 停用aspirin 繼續使用 P2Y12抑制劑, 以減少消化道出血機率

P2Y12抑制劑包括

Clopidogrel (保栓通 / Plavix)

Ticagrelor (百無凝 / Brilinta)

Prasugrel (抑凝安 / Efient)：

Aspirin has long been considered an integral part of antiplatelet therapy to prevent recurrent atherothrombotic events among patients with ACS.1–3,6 Aspirin reduces the incidence of vascular death after AMI,3 and in secondary prevention trials (that include patients after MI), it reduces the occurrence of vascular and coronary events, including MI and stroke.2 Although aspirin use after ACS was traditionally considered lifelong, a strategy of aspirin discontinuation, rather than P2Y12 inhibitor discontinuation, may now be considered in the maintenance phase after 1 to 3 months in selected patients to reduce risk of bleeding (Section 11.1, “DAPT Strategies in the First 12 Months Postdischarge”). 

做完 PCI 1-4 周之後. 若患者已經在使用完全劑量的抗凝血劑合併 P2Y12抑制劑. 可考慮停用 aspirin

若患者到院後發現無法使用aspirin. 則應儘早使用完整初始劑量的 P2Y12抑制劑.

Aspirin discontinuation after 1 to 4 weeks after PCI is also appropriate for patients on a full-dose anticoagulant in combination with continued use of a P2Y12 inhibitor (Section 11.1.1, “Antiplatelet Therapy in Patients on Anticoagulation Postdischarge”). 

對於aspirin敏感的患者. 建議aspirin去敏治療(在院內有監視的狀況下, 每隔幾小時至幾天. 給予少劑量 aspirin. 以使用雙重抗血小板治療. 

For patients in whom a history of aspirin hypersensitivity is reported, aspirin desensitization is preferred whenever possible to allow for initial use of dual antiplatelet therapy.7–9 The use of a P2Y12 inhibitor is recommended in all patients with ACS regardless of whether they have a history of aspirin hypersensitivity, but should be administered with a loading dose as early as possible for those patients unable to take aspirin at presentation.

Table 7. Dosing Considerations for Oral Antiplatelet Therapy in Patients With ACS

Agent	Setting	Dosing Considerations
Aspirin	NSTE-ACS or STEMI	Loading dose 162-325 mg orally. Aspirin (nonenteric coated) should be chewed, when possible, to achieve faster onset of antiplatelet action. Loading dose should be administered for patients already on aspirin therapy. Maintenance dose 75-100 mg orally daily (nonenteric coated)
Clopidogrel	NSTE-ACS or STEMI without fibrinolytic	Loading dose 300 or 600 mg orally Maintenance 75 mg orally daily
	STEMI with fibrinolytic	Loading dose 300 mg orally if age ≤75 y; Initial dose 75 mg orally if age >75 y Maintenance 75 mg orally daily
Prasugrel	NSTE-ACS or STEMI without fibrinolytic, and undergoing PCI	Loading dose 60 mg orally Maintenance dose 10 mg orally daily if body weight ≥60 kg and age <75 y Maintenance dose 5 mg orally daily if body weight <60 kg or age ≥75 y (use caution)
Ticagrelor	NSTE-ACS or STEMI without fibrinolytic	Loading dose 180 mg orally Maintenance dose 90 mg orally twice daily

4.3.2. Oral P2Y12 Inhibitors During Hospitalization

STEMI患者如果沒做PCI而是使用血栓溶解劑. 仍建議給予 plavix. 

跳過 4.4 抗凝血劑. 4.5 降血脂藥物

4.6

24小時內給予乙型阻斷劑可減少再次梗塞及心室心律不整機率

4.6. Beta-Blocker Therapy

跳過標準治療最後一項 4.7

4.7. Renin-Angiotensin-Aldosterone System Inhibitors