A Shift in Mindset: From ST Elevation to Acute Coronary Occlusion Myocardial Infarction (ACOMI)

Acute coronary syndrome (ACS) remains a leading cause of morbidity and mortality worldwide. Within ACS subtypes, ST-elevation myocardial infarction (STEMI) has traditionally been associated with the highest risk of death and morbidity due to complete or near complete occlusion of an epicardial coronary artery, warranting emergent reperfusion. As a result, global systems of care have been created to rapidly identify and treat patients with STEMI. However, a growing body of evidence and the latest Australian ACS guidelines, have highlighted a critical limitation of the traditional STEMI mindset; not all patients with acute coronary occlusion myocardial infarction (ACOMI) exhibit ST elevation on electrocardiography (ECG). These 'STEMI-equivalent' presentations have similar outcomes to patients with classical ST elevation yet are not treated within the same care pathways. Early identification and reperfusion in ACOMI may have the potential to improve cardiovascular outcomes. A deeper understanding of the ECG and clinical markers of acute coronary occlusion, beyond traditional ST elevation criteria, is essential for timely diagnosis and intervention. This review explores the emerging concept of ACOMI, underscores its clinical implications and advocates for a shift in mindset in the evaluation and management of acute myocardial infarction.