Diagnosis of occlusion myocardial infarction

To summarize the emerging paradigm of acute coronary occlusion myocardial infarction (OMI), with a practical overview of clinical assessment, ECG advances, and the role of bedside echocardiography and troponin.

ST-elevation MI (STEMI) millimeter criteria are a poor surrogate marker for OMI, with high rates of false positives (STE without OMI) and false negatives (OMI without STE). The OMI paradigm shift maximizes the capabilities of the ECG while putting these findings into clinical context. OMI is a clinical diagnosis that starts with assessment for anginal symptoms, whether they are continuous or resolved, and whether the patient is stable or unstable. Evidence-based ECG advances have addressed multiple diagnostic dilemmas in the STEMI paradigm to identify false positive and subtle occlusions. OMI ECG signs double the sensitivity of STEMI criteria, maintain high specificity, and can be learned by AI. Regional wall motion abnormalities on bedside ultrasound can complement clinical and ECG signs. The initial troponin has limited sensitivity and predictive value in OMI.

The OMI paradigm shift uses clinical features, ECG/POCUS findings and judicious use of troponin to identify patients in need of emergent reperfusion.