Thursday, December 10, 2020

Our newest OMI publication, in JEM - Comparison of the STEMI vs. NSTEMI and Occlusion MI vs. NOMI paradigms of acute MI

See our newest OMI publication in JEM

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Comparison of the ST-elevation myocardial infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI paradigms of acute MI

Background: The current ST-elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) paradigm prevents some NSTEMI patients with acute coronary occlusion from receiving emergent reperfusion, in spite of their known increased mortality compared with NSTEMI without occlusion. We have proposed a new paradigm known as occlusion MI vs. nonocclusion MI (OMI vs. NOMI).

Objective: We aimed to compare the two paradigms within a single population. We hypothesized that STEMI(–) OMI would have characteristics similar to STEMI(+) OMI but longer time to catheterization.

Methods: We performed a retrospective review of a prospectively collected acute coronary syndrome population. OMI was defined as an acute culprit and either TIMI 0–2 flow or TIMI 3 flow plus peak troponin T greater than or equal to 1.0 ng/mL. We collected electrocardiograms, demographic characteristics, laboratory results, angiographic data, and outcomes.

Results: Among 467 patients, there were 108 OMIs, with only 60% (67 of 108) meeting STEMI criteria. Median peak troponin T for the STEMI(+) OMI, STEMI(–) OMI, and no occlusion groups were 3.78 (interquartile range [IQR] 2.18–7.63), 1.87 (IQR 1.12– 5.48), and 0.00 (IQR 0.00–0.08). Median time from arrival to catheterization was 41 min (IQR 23–86 min) for STEMI(+) OMI compared with 437 min (IQR 85– 1590 min) for STEMI(–) OMI (p less than 0.001). STEMI(+) OMI was more likely than STEMI(–) OMI to undergo catheterization within 90 min (76% vs. 28%; p less than 0.001).

Conclusions: STEMI(–) OMI patients had significant delays to catheterization but adverse outcomes more similar to STEMI(+) OMI than those with no occlusion. These data support the OMI/NOMI paradigm and the importance of further research into emergent reperfusion for STEMI(–) OMI.

If your understanding of ACS stops at the STEMI vs. NSTEMI concept, then this figure below appears at first glance to justify and summarize your practice: 

But in reality, the paradigm keeps an important population hidden from your understanding: the NSTEMI patients with OMI. Their peak troponins were similar to the obvious STEMIs, and of course they both have OMI.

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