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

Abstract

Background Although ST-segment elevation (STE) has been used synonymously with acute coronary occlusion (ACO), current STE criteria miss nearly one-third of ACO and result in a substantial amount of false catheterization laboratory activations. As many other electrocardiographic (ECG) findings can reliably indicate ACO, we sought whether a new ACO/non-ACO myocardial infarction (MI) paradigm would result in better identification of the patients who need acute reperfusion therapy. Methods A total of 3000 patients were enrolled in STEMI, non-STEMI and control groups. All ECGs were reviewed by two cardiologists, blinded to any outcomes, for the current STEMI criteria and other subtle signs. A combined ACO endpoint was composed of peak troponin level, troponin rise within the first 24 h and angiographic appearance. The dead or alive status was checked from hospital records and from the electronic national database. Results In non-STEMI group, 28.2% of the patients were re-classified by the ECG reviewers as having ACO. This subgroup had a higher frequency of ACO, myocardial damage, and both in-hospital and long-term mortality compared to non-STEMI group. A prospective ACOMI/non-ACOMI approach to the ECG had superior diagnostic accuracy compared to the STE/non-STEMI approach in the prediction of ACO and long-term mortality. In Cox-regression analysis early intervention in patients with non-ACO-predicting ECGs was associated with a higher long-term mortality. Conclusions We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI. (DIFOCCULT study; ClinicalTrials.gov number, NCT04022668.)

Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction

“…In contrast, our blinded interpreters were able to more than double the sensitivity of the STEMI criteria for OMI, with similar specificity. Our ability to reclassify NSTEMIs as STEMI(−) OMI externally confirms the results of Aslanger et al who also recently demonstrated the potential of the OMI paradigm [7] . Our interpreters exhibited very high interrater reliability among many ECGs, which is likely attributable to the fact that Interpreter 2 has been trained extensively by Interpreter 1.…”

“…Investigators find many patients with OMI have STE that does not meet STEMI criteria, and have found many other ECG indicators of OMI, including hyperacute T-waves, terminal QRS distortion, low QRS amplitude, and more [6] . Aslanger et al recently reclassified 28% of NSTEMIs as OMI with structured interpretation using predefined OMI ECG findings, identifying a group with similar lesions and outcomes as STEMI [7] . Furthermore, some OMI have no ECG manifestations and must be diagnosed by a combination of clinical suspicion, ongoing symptoms, biomarker elevation, echocardiography, or even coronary computed tomography angiography [8] , [9] , [10] .…”

“…Although STE is insufficient to detect many cases of OMI, there are many other ECG findings [6] of OMI, which may improve both the sensitivity and specificity of the ECG compared to STEMI criteria, as Aslanger showed among cardiologist interpreters [7] . However, this has not yet been studied among emergency physicians.…”

Time for a new paradigm shift in myocardial infarction

“…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.…”

Diagnosis of Occlusion Myocardial Infarction in Patients with Left Bundle Branch Block and Paced Rhythms

“…The most widely recognizable and accepted ECG feature of OMI is ST-elevation (STE) meeting criteria specified in the Fourth Universal Definition of Myocardial Infarction (UDMI) [1]. However, not all OMIs manifest STE meeting these criteria, or even any STE at all [2,3]. Among the many OMIs not captured by the STE criteria are OMI associated with left bundle branch block (LBBB) and Right Ventricular Pacing (RVP).…”