Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI

Meyers, H. Pendell; Bracey, Alexander; Lee, Daniel; Lichtenheld, Andrew; Li, Wei J.; Singer, Daniel; Kane, Jesse; Dodd, Kenneth W.; Meyers, Kristen; Thode, Henry C.; Shroff, Gautam R.; Singer, Adam J.; Smith, Stephen W.

doi:10.1016/j.jemermed.2020.10.026

Cited by 67 publications

(59 citation statements)

References 46 publications

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“…Even if all such trials were free of these methodological issues and had instead shown no benefit, they still would not be applicable to the question of whether the subset of NSTEMIs with ACO benefit from emergent reperfusion because these trials did not report the presence or absence of angiographic ACO, much less the outcomes in these patients. These findings have 2 important messages with the same implication: We need to reshape our minds to understand that ACO needing reperfusion is clearly not synonymous with STEMI because NSTEMI with unrecognized ACO has higher short and long-term risk of mortality than NSTEMI with an open artery and similar to STEMI (39,40). In addition, although the current guidelines recommend urgent (<2 hours) invasive evaluation "regardless of ECG or biomarker findings" in patients with persistent pain, hemodynamic compromise, severe heart failure, and/or arrhythmias to identify patients with ACO but without STE (17)(18)(19), these clinical parameters did not compensate for the silence of the ECG in the abovementioned studies.…”

Section: Caveats Of the Stemi/nstemi Paradigmmentioning

confidence: 99%

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Time for a new paradigm shift in myocardial infarction

Aslanger

Meyers

Smith

2021

Anatolian J Cardiol

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The ST-elevation myocardial infarction (STEMI)/non-STEMI paradigm per the current guidelines has important limitations. It misses a substantial proportion of acute coronary occlusions (ACO) and results in a significant amount of unnecessary catheterization laboratory activations. It is not widely appreciated how poor is the evidence base for the STEMI criteria; the recommended STEMI cutoffs were not derived by comparing those with ACO with those without and not specifically designed for distinguishing patients who would benefit from emergency reperfusion. This review aimed to discuss the origins, evidence base, and limitations of STEMI/non-STEMI paradigm and to call for a new paradigm shift to the occlusion MI (OMI)/non-OMI.

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Section: Caveats Of the Stemi/nstemi Paradigmmentioning

confidence: 99%

“…Another study by Meyers et al (40) compared the STEMI/ NSTEMI with the OMI/NOMI paradigms in 467 consecutive patients with high-risk acute coronary syndrome. Among the 108 patients with OMI, only 60% had any ECG meeting STEMI criteria.…”

Section: Stemi/nstemi Paradigm Is Not Our Best Optionmentioning

confidence: 99%

Time for a new paradigm shift in myocardial infarction

Aslanger

Meyers

Smith

2021

Anatolian J Cardiol

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“…This includes the 25% or more of NSTEMI patients with occluded arteries on angiogram and the third of true STEMI patients that have an open artery by the time of angiogram. In order to identify all patients with an occluded artery at ED presentation, the definition of OMI includes the following: (1) confirmed OMI (angiographic culprit lesion with TIMI 0-2 flow), and (2) presumed OMI with significant cardiac outcome, defined as: (a) angiographic acute but non-occlusive culprit lesion with highly elevated troponin (as defined in several studies, between 70 and 300 times the 99th percentile upper reference limit, depending on the assay), (b) highly elevated troponin and new regional wall motion abnormality on echocardiography, in those without angiography, or (c) STEMI(+) ECG with death before angiogram [7][8][9]. EDs can design QI interventions based on this outcome, and target the different components of the reperfusion decision (Table 2).…”

Section: Omi Paradigm and Qimentioning

confidence: 99%

From STEMI to occlusion MI: paradigm shift and ED quality improvement

et al. 2021

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A generation ago the ST-elevation myocardial infarction (STEMI) paradigm led to quality improvement (QI) in the emergency department (ED). Now, insights from angiography and advances in electrocardiogram (ECG) interpretation have led to the new paradigm of occlusion myocardial infarction (OMI), creating the possibility of further QI. This article reviews the current STEMI paradigm, the emergence of the OMI paradigm, and the use of QI to continuously improve care for acute myocardial infarction (AMI) patients in the ED.

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“…While the presence of STE on ECG is helpful, not all acute coronary occlusions present with STE or meet the STEMI Criteria and are classified as non-ST-elevation myocardial infarction (STEMI) with the addition of positive cardiac biomarkers. A recent retrospective chart review of 467 high-risk acute coronary syndrome patients found that 40% of patients with OMI did not demonstrate STEMI criteria on ECG, which led to delayed cardiac catheterization and increased morbidity and mortality [ 6 ]. In our case, the patient’s pre-hospital ECG ( Figure 1 ) demonstrated a regular rhythm absent of P waves, with right axis deviation, left posterior fascicular block, intraventricular conduction delay (QRS >100 ms), ST-waves with a high-takeoff, STE at the J point in lead V1 of greater than 2.5 mm, and what appeared as J point elevation in V2, both followed by T wave inversions.…”

Section: Discussionmentioning

confidence: 99%

Brugada Pattern Manifesting During Hyperkalemia, Diabetic Ketoacidosis, and Acute Alcohol Intoxication

et al. 2021

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Patient: Male, 28-year-old Final Diagnosis: Alcohol intoxication • Brugada pattern • diabetic ketoacidosis • hyperkalemia Symptoms: Encephalopathy Medication:— Clinical Procedure: — Specialty: Cardiology Objective: Rare disease Background: Brugada syndrome is a rare ion channelopathy that can lead to sudden cardiac death and lethal arrhythmias in patients without a structural cardiac defect, the most common of which being the gain-of-function mutation of the SCN5a sodium ion channel involving phase 0 of the cardiac action potential. In 2012, BrS electrocardiogram findings were redefined and classified as either congenital Brugada syndrome (BrS) or Brugada pheno-copies (BrP). Several etiologies of BrP have been reported, such as metabolic derangements, electrolyte abnormalities, cardiovascular diseases, and pulmonary embolism. Case Report: A 28-year-old man presented to the Emergency Department unresponsive. An initial ECG taken by Emergency Medical Services (EMS) was interpreted as a STEMI. An initial ECG in the ED showed a Brugada type I ECG pattern in leads V1-V2 and hyperacute T wave abnormalities, among other findings. Additionally, the patient had a serum potassium level of 9 mmol/L, glucose level of 1375 mmol/L, and peak cardiac troponin-I of 20.452 μg/L. All underlying medical conditions were stabilized, electrolyte and metabolic abnormalities were corrected, and subsequent normalization of electrocardiographic findings was achieved. Conclusions: Distinguishing congenital Brugada syndrome from Brugada phenocopies can be difficult, especially when patients present to the ED with severe underlying conditions. Several factors can be used to direct clinical suspicion towards one or the other; however, confirmation may require EP studies and further tests. In this case, the following findings were suggestive of BrP: presence of an identifiable underlying abnormality, correction of the underlying condition resolves the ECG pattern, and the absence of family history of sudden cardiac death.

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Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI

Cited by 67 publications

References 46 publications

Time for a new paradigm shift in myocardial infarction

Time for a new paradigm shift in myocardial infarction

From STEMI to occlusion MI: paradigm shift and ED quality improvement

Brugada Pattern Manifesting During Hyperkalemia, Diabetic Ketoacidosis, and Acute Alcohol Intoxication

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