Acute coronary-occlusion myocardial infarctions: performance of the STEMI criteria and evolving alternative
Ryan Tudino1, Edward Richardson1, Jessica M Gonzalez1
1Department of Internal Medicine, Rhode Island Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA.
Insights
Acute coronary syndrome (ACS) management differs based on ST-elevation myocardial infarction (STEMI) criteria. "STEMI-equivalents" in non-STEMI ACS may indicate acute coronary occlusion, warranting further investigation for timely reperfusion.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Diagnostics
Background:
- Acute coronary syndrome (ACS) encompasses STEMI, NSTEMI, and UA, primarily caused by atherothrombosis and coronary artery occlusion.
- Current guidelines dictate varied coronary angiogram timing for ACS, with STEMI patients prioritized for immediate catheterization.
- NSTEMI patients often receive delayed reperfusion, despite a significant proportion having acute coronary occlusion (ACO).
Purpose of the Study:
- To review literature on acute coronary occlusion myocardial infarction (ACOMI) within NSTEMI ACS.
- To examine the diagnostic and clinical significance of "STEMI-equivalents" in NSTEMI.
- To explore strategies for improved risk stratification in NSTEMI ACS.
Main Methods:
- Literature review of ACOMI and "STEMI-equivalents" in NSTEMI ACS.
- Analysis of current diagnostic criteria and guideline recommendations.
- Discussion of potential for revised criteria and predictive tools.
Main Results:
- A substantial subset of NSTEMI ACS patients present with ACO.
- "STEMI-equivalents" are recognized high-risk features in expert statements but not formally adopted in guidelines.
- Current diagnostic and triage strategies may not optimally identify all NSTEMI patients requiring urgent reperfusion.
Conclusions:
- "STEMI-equivalents" represent a critical area for further research in NSTEMI ACS.
- Revised diagnostic criteria and predictive tools are needed to better stratify NSTEMI ACS patients for reperfusion therapy.
- Optimizing triage for NSTEMI ACS could improve outcomes by identifying patients with ACO.
Abstract:
Acute coronary syndrome (ACS) includes ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA), which occur predominantly due to atherothrombosis with varying degrees of acute occlusion of coronary vasculature. Coronary angiogram and subsequent percutaneous coronary intervention (PCI) are central to management of acute coronary occlusions; however, the timing of coronary angiogram varies significantly across these pathologies based on current guidelines. The STEMI criteria are electrocardiographic features utilized to rapidly triage patients to catheterization laboratories, because these criteria are felt to be specific for acute coronary occlusion of culprit coronary vessels. Patients who do not fulfill STEMI criteria are triaged as NSTEMIs with delayed coronary reperfusion strategies. A significant proportion of patients with NSTEMI ACS are found to have acute coronary occlusion (ACO) of coronary vessels. Some NSTEMI patterns on electrocardiogram that are considered specific for acute coronary occlusion myocardial infarction (ACOMI) have been aptly labeled "STEMI-equivalents" and are thus recognized as high-risk features in expert statements but, as of yet, not formally adopted in guidelines. Here, we review the current literature on ACOMI in NSTEMI ACS and the "STEMI Equivalents". We discuss the potential role for additional studies, revised diagnostic criteria, and predictive tools to better stratify patients with NSTEMI ACS for urgent versus delayed reperfusion.
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