A Simplified Formula Discriminating Subtle Anterior Wall Myocardial Infarction from Normal Variant ST-Segment Elevation

DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study)

“…S2 ) [18] , hyperacute T-waves or de Winter’s pattern in 35 (12.4%) ( Fig. S3 ) [22] , [23] , subtle anterior STE in 18 (6.3%) [19] , [20] and nonconsecutive STE in 14 (4.9%) of the patients [21] . The reason for less pronounced ECG changes in this group may partly be explained by the more limited infarct size as indicated by the lower 24 to 48-hour troponin I level (5.703 [IQR 19.347] ng/ml vs. 32.990 [43.356] ng/ml in STEMI-group, P < 0.001) and higher left ventricular ejection fraction (50% [IQR 20%] vs. 45% [20%], respectively; P < 0.001), and/or involvement of an electrocardiographically silent area as indicated by the more frequent involvement of the circumflex artery as the infarct-related artery (27.9% vs. 17.8%, respectively, P = 0.001).…”

“…However, the term STEMI restricts our thinking to the point that it is only the ST-segment that matters for the reperfusion decision, with no consideration of any other ECG variables, such as the preceding QRS-complex, the T-wave, or even the morphology of ST-segment itself. Recent studies clearly indicated that any STE should be interpreted in the context of other ECG variables [19] , [20] . Additionally, the term STEMI is somewhat self-contradictory, since a patient without STE on ECG, but ACO on the angiogram, is still classified as non-STEMI.…”

“…reviewed all ECGs twice, three months apart, for the assessment of intra-observer variability. Using 12-lead information and a set of predefined ECG findings [18] , [19] , [20] , [21] , [22] , [23] the reviewers also attempted to predict whether an ACO was present and classified ECGs into a diagnostic category as defined previously (Table S1) [26] . If present and needed, ECGs with additional leads were also included in the analysis.…”

“…Accordingly, several authors called for a new paradigm shift from STEMI/non-STEMI to ACO-MI/non-ACO-MI [17] , [18] , [19] , as ACO can be reliably recognized with the help of many other ECG findings, such as minor STE not fulfilling STEMI criteria [18] , STE disproportionate to preceding QRS [19] , [20] , unusual patterns with contiguous leads showing opposite ST deviations [21] and some patterns not showing STE at all [22] , [23] . However, it is uncertain whether this new approach would result in better identification of the patients who need acute reperfusion therapy and/or whether the ECG has sufficient diagnostic power to go beyond established STEMI criteria.…”

Time for a new paradigm shift in myocardial infarction

“…It leads us to ignore other ECG variables, such as the preceding QRS-complex, the T-wave, or even the morphology of ST-segment itself. However, ACO can be reliably recognized with the help of many ECG findings other than the STE cutoffs recommended by the 4 th universal definition of MI, such as minor STE not fulfilling STEMI criteria (41), STE disproportionate to preceding QRS (42,43), unusual patterns with contiguous leads showing opposite ST deviations (44,45), and some patterns not showing STE at all (46,47). The universal definition does in fact mention that there are other ECG findings of ACO than STE, which supports the argument that the name of ACO-MI should not be STEMI, but rather occlusion MI (OMI).…”