The illusion of simplicity: Diagnostic inconsistencies within the STEMI paradigm

The ST-elevation myocardial infarction (STEMI) paradigm relies on the assumption that specific millimeter-based ST-segment elevation criteria serve as a reliable surrogate for acute coronary occlusion. While proponents advocate for the simplicity and uniformity of these criteria, the paradigm often fails to reflect the underlying pathophysiologic reality captured in the Occlusion Myocardial Infarction (OMI) paradigm.

A 65-year-old male presented with acute chest pain and an initial electrocardiogram (ECG) specific for left anterior descending coronary artery (LAD). Despite these findings, the ECG was negative for STEMI millimeter criteria. Management was delayed as the patient was categorized as having a non-ST elevation myocardial infarction (NSTEMI). Coronary angiography performed 15 h after presentation revealed an acute total thrombotic occlusion of the LAD.

This case illustrates the "illusion of simplicity" within the STEMI paradigm, where clinical documentation and intervention timing were dictated more by benchmark-driven diagnostic labels than by objective evidence of coronary occlusion. Evidence suggests that standard STEMI criteria fail to identify up to 38% of LAD occlusions, whereas expert interpretation and AI models have far higher sensitivity.

The STEMI paradigm's purported uniformity is inconsistent over time and often reflects physician attainment of "door-to-balloon" metrics rather than the patient's physiological state. To improve diagnostic accuracy and patient outcomes, clinical practice must transition from the STEMI paradigm to the more physiologically accurate OMI paradigm.