Friday, July 31, 2020

OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article


OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article by Emre Aslanger, with some help from Smith

"ACOMI" = Acute Coronary OMI

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

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MY Comment by KEN GRAUER, MD (7/31/2020):
In the April 1, 2018 post in Dr. Smith’s ECG Blog — Drs. Meyers, Weingart and Smith published their OMI Manifesto — in which they extensively document the critically important concept that management of acute MI by separation into a “STEMI” vs “non-STEMI” classification is an irreversibly flawed approach.
  • Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! Yet despite this remarkable flaw in the STEMI-paradigm — a substantial number (if not a frank majority) of clinicians continue to apply outdated criteria when interpreting ECGs, by refusing to consider prompt cath for definitive diagnosis and reperfusion therapy just because a millimeter-based definition for acute STEMI is not satisfied.

In the hope of dispelling continued dependence on millimeter-based STEMI criteria — we’ve published numerous cases in recent years in Dr. Smith’s ECG Blog of acute OMI (Occlusion-based Myocardial Infarction), in which patients have benefited from acute reperfusion despite not satisfying “STEMI criteria”.
  • The article by Aslanger, Smith et al that is featured above in today’s post has just been published. It is notable for providing additional evidence in support of making a paradigm shift away from the far less efficient “STEMI” vs “non-STEMI” approach — to acceptance of a newer approach that recognizes other ECG indicators that tell us the patient in front of us who is having new cardiac symptoms is very likely to have ACO (Acute Coronary Occlusion) — and is therefore in need of prompt cath and acute reperfusion despite having an ECG that may lack the millimeter definition of a STEMI.

NOTE: The following ECG findings, when seen in association with new cardiac symptoms are among those that suggest acute OMI despite not satisfying the millimeter-based definition of a STEMI:
  • Hyperacute T waves (that are disproportionately tall and/or fatter-at-their-peak or wider-at-their-base than should be expected given R wave and S wave amplitude in that lead). The more leads in a given lead area that show hyperacute changes — the greater the concern for acute OMI.
  • Terminal QRS distortion (ie, the absence of both a J-wave and an S-wave in either lead V2 or lead V3) — SEE My Comment in the November 14, 2019 post for an illustration and description of T-QRS-D.
  • Suspicious-looking ST elevation not satisfying STEMI-criteria — especially when there is reciprocal ST-T wave depression and/or abnormal ST segment shaping in other leads. The more leads with suspicious findings — the greater the concern for an acute ongoing event.
  • Any ST elevation in inferior leads that occurs in association with mirror-image opposite ST depression in lead aVL.
  • ST depression that is maximal in leads V2-to-V4.
  • The finding of dynamic ST-T wave changes on serial tracings in association with a change in chest pain symptoms (SEE My Comment in the July 21, 2020 post).

  • BOTTOM Line: It takes time (and some practice) — to adjust to the concept that we can get good at accurately and confidently recognizing many cases of acute coronary occlusion, even when millimeter-defined STEMI criteria are not met. The above-cited newly published article by Aslanger, Smith et al provides further support to the growing body of literature of why we should compel ourselves to do so.

  • P.S.: Our September 3, 2020 post features Dr. Meyers' 17-minute summary of the OMI Manifesto.

  • P.P.S. (1/14/2023): I am adding this newest reference by McLaren, Meyers & Smith (J Electrocardiol 76:39-44, 2023) — based on the recent talk presented by Dr. Smith at the International Society of Computers in Electrocardiology — which provides a superb summary on the new OMI (vs STEMI) Paradigm. Failure to adapt the OMI paradigm will only lead to continued misunderstanding in the cardiology literature that has been "stuck" insisting on outdated STEMI criteria (that miss at least 30% of all acute occlusion MIs! ).

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