Missing occlusions: Quality gaps for ED patients with occlusion MI
Jesse T T McLaren1, Mazen El-Baba2, Varunaavee Sivashanmugathas3
1Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Emergency Department, University Health Network, Toronto, Ontario, Canada.
Insights
ST-elevation Myocardial Infarction (STEMI) guidelines overlook false negatives. The occlusion myocardial infarction (OMI) paradigm reveals that most OMI cases are missed, indicating significant quality gaps in acute coronary syndrome care.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Accuracy
Background:
- Current ST-elevation Myocardial Infarction (STEMI) guidelines focus on monitoring false positives but neglect false negatives (non-STEMI with occlusion myocardial infarction [OMI]).
- Evaluating emergency department (ED) patients with acute coronary syndrome (ACS) using STEMI versus OMI paradigms is crucial for understanding diagnostic gaps.
Purpose of the Study:
- To assess the hospital course of ED patients with ACS under both STEMI and OMI diagnostic paradigms.
- To identify discrepancies in diagnosis and treatment between STEMI and OMI classifications.
Main Methods:
- Retrospective chart review of ACS patients admitted to two academic EDs from June 2021 to May 2022.
- Patients were categorized into OMI, Non-OMI (NOMI), or MI ruled out (MIRO) based on specific angiographic and troponin criteria.
- Initial ECGs were analyzed for STEMI interpretation, and admission/discharge diagnoses were compared.
Main Results:
- Out of 382 patients, 141 had OMI, 181 NOMI, and 60 MIRO.
- Only 40.4% of OMIs were admitted as STEMI, with significantly longer door-to-cath times for those not admitted as STEMI (1712 min vs. 103 min).
- A substantial proportion of Non-STEMI patients (32.0%) actually had OMI but were discharged with a Non-STEMI diagnosis.
Conclusions:
- The current STEMI criteria fail to identify the majority of OMI cases, leading to potential underdiagnosis and delayed treatment.
- The OMI paradigm highlights significant quality gaps in ACS care, particularly concerning false-negative STEMI diagnoses.
- Implementing the OMI paradigm can improve diagnostic accuracy and patient outcomes in acute coronary syndromes.
Background:
ST-elevation Myocardial Infarction (STEMI) guidelines encourage monitoring of false positives (Code STEMI without culprit) but ignore false negatives (non-STEMI with occlusion myocardial infarction [OMI]). We evaluated the hospital course of emergency department (ED) patients with acute coronary syndrome (ACS) using STEMI vs OMI paradigms.
Methods:
This retrospective chart review examined all ACS patients admitted through two academic EDs, from June 2021 to May 2022, categorized as 1) OMI (acute culprit lesion with TIMI 0-2 flow, or acute culprit lesion with TIMI 3 flow and peak troponin I >10,000 ng/L; or, if no angiogram, peak troponin >10,000 ng/L with new regional wall motion abnormality), 2) NOMI (Non-OMI, i.e. MI without OMI) or 3) MIRO (MI ruled out: no troponin elevation). Patients were stratified by admission for STEMI. Initial ECGs were reviewed for automated interpretation of "STEMI", and admission/discharge diagnoses were compared.
Results:
Among 382 patients, there were 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIs were admitted as STEMI: 60.0% had "STEMI" on ECG, and median door-to-cath time was 103 min (IQR 71-149). But 59.6% of OMIs were not admitted as STEMI: 1.3% had "STEMI" on ECG (p < 0.001) and median door-to-cath time was 1712 min (IQR 1043-3960; p < 0.001). While 13.9% of STEMIs were false positive and had a different discharge diagnosis, 32.0% of Non-STEMIs had OMI but were still discharged as "Non-STEMI."
Conclusions:
STEMI criteria miss a majority of OMI, and discharge diagnoses highlight false positive STEMI but never false negative STEMI. The OMI paradigm reveals quality gaps and opportunities for improvement.
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