What the electrocardiogram is being asked to detect in acute myocardial infarction: The case for the OMI/NOMI
1Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil.
Insights
The current electrocardiogram (ECG) standard for heart attacks misses critical cases. An updated interpretation focusing on coronary artery occlusion, not just ST elevation, improves diagnosis and treatment for acute myocardial infarction (AMI).
Area of Science:
- Cardiology
- Medical Diagnostics
- Emergency Medicine
Background:
- The current interpretation of electrocardiograms (ECGs) for suspected acute myocardial infarction (AMI) relies heavily on ST-segment elevation thresholds.
- A significant portion of patients diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI) have total coronary artery occlusion, leading to severe outcomes comparable to ST-segment elevation myocardial infarction (STEMI).
- This suggests that delayed reperfusion, not baseline patient risk, drives adverse outcomes in NSTEMI with occlusion.
Purpose of the Study:
- To re-evaluate the standard ECG interpretation for AMI.
- To introduce and examine the occlusion myocardial infarction (OMI) versus non-occlusion myocardial infarction (NOMI) framework.
- To assess the arguments for and against the ST-elevation-only reading standard and explore the potential of an expanded interpretation.
Main Methods:
- Review of existing evidence and arguments regarding ECG interpretation standards for AMI.
- Analysis of diagnostic paradigms and historical clinical trial data in NSTEMI.
- Examination of the potential for an expanded ECG reading standard, including AI-driven interpretation.
Main Results:
- The current ST-elevation-only criterion is insufficient and leads to delayed diagnosis and treatment for OMI.
- Historical trials in NSTEMI were not adequately designed to assess early reperfusion benefits in occluded arteries.
- An expanded ECG interpretation framework, particularly when augmented by artificial intelligence, demonstrates improved sensitivity and specificity for detecting acute coronary occlusion.
Conclusions:
- The limitations in diagnosing AMI stem from the restrictive reading standard applied to ECGs, not the ECG technology itself.
- An OMI/NOMI framework offers a more accurate approach to ECG interpretation, guiding timely and appropriate reperfusion strategies.
- Implementing an expanded, AI-scalable ECG interpretation standard is crucial for improving patient outcomes in acute myocardial infarction.
Abstract:
The electrocardiogram is the pivotal triage instrument in suspected acute myocardial infarction, yet for three decades its interpretation has been reduced to a single feature: whether ST-segment elevation meets a fixed millimeter threshold. Approximately one-quarter to one-third of patients labeled non-ST-segment elevation myocardial infarction (NSTEMI) harbor total culprit artery occlusion at next-day angiography, sustain infarct sizes and mortality comparable to or worse than ST-segment elevation myocardial infarction (STEMI), and are younger and less comorbid - indicating that adverse outcomes reflect delayed reperfusion rather than baseline risk. The occlusion myocardial infarction versus non-occlusion myocardial infarction (OMI/NOMI) framework reorients electrocardiographic interpretation around acute coronary occlusion rather than a single morphological criterion. This review examines the principal arguments advanced in defense of the ST-elevation-only reading standard as electrocardiographic propositions: what the electrocardiogram is being asked to detect, what it predicts when read for occlusion, how its interpretation shapes the timing and selection of reperfusion, and whether an expanded reading standard can be operationalized without loss of diagnostic performance. The evidence shows that the call for dedicated randomized trials misunderstands a purely diagnostic paradigm, that early-invasive trials in NSTEMI were neither early nor selective, that fibrinolytic benefit in non-ST-elevation occlusion was obscured by heterogeneous pooling, and that expanded interpretation - increasingly scalable through artificial intelligence - improves sensitivity and specificity simultaneously. The electrocardiogram has not failed; the reading standard applied to it has.
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