Time for a new paradigm shift in myocardial infarction

Abstract

The ST-elevation myocardial infarction (STEMI)/non-STEMI paradigm per the current guidelines has important limitations. It misses a substantial proportion of acute coronary occlusions (ACO) and results in a significant amount of unnecessary catheterization laboratory activations. It is not widely appreciated how poor is the evidence base for the STEMI criteria; the recommended STEMI cutoffs were not derived by comparing those with ACO with those without and not specifically designed for distinguishing patients who would benefit from emergency reperfusion. This review aimed to discuss the origins, evidence base, and limitations of STEMI/non-STEMI paradigm and to call for a new paradigm shift to the occlusion MI (OMI)/non-OMI.

Acute Coronary Syndrome Requires (or Not) an Immediate Reperfusion Strategy: It Is Time to Change the Paradigm

“…Recently, Aslanger et al 4 have published a review where they state that, beyond STEMI, there are certain clinical characteristics in patients with NSTE-ACS that require and benefit from an immediate reperfusion strategy which is in accordance with other authors. 5 …”

Clinical Features of the Aslanger Pattern to Compensate for the Limitation of ST-Elevation Myocardial Infarction (STEMI) Criteria

“…STEMI criteria alone may not be sufficient to rule in all acute coronary artery occlusions. Aslanger et al reported that we needed to recognize subtle ECG changes in treating in the patients with acute coronary syndrome [6][7][8][9]. Therefore, Pendell Meyers et al reported that other diagnostic tools need to be determined to compensate for STEMI criteria [10].…”

Beyond the ST-segment in Occlusion Myocardial Infarction (OMI)

“…Pooled data from these trials were studied in the seminal fibrinolytic therapy trialists’ meta-analysis,[ 6 ] which showed an impressive reduction in mortality with a slightly better benefit in patients with (ambiguously and inconsistently defined) STE compared to general cohort. [ 1 ] This was an unparalleled revolution in cardiology which made “reperfusion medicine” the norm.…”

“…[ 13 14 15 16 17 18 19 20 21 ] This suggests that, when STEMI criteria are not met, the physicians do not manage to identify the patients with ACO among all patients with undifferentiated persistent chest pain partly because it may be present in many other competing diagnoses. [ 1 2 ] Furthermore, STEMI criteria were shown to have only a prospective sensitivity of 21% and 49% for ACO when a computer algorithm and cardiologist evaluation were used, respectively. [ 22 ] Physicians across different specialties have poor accuracy and poor interrater reliability for detecting ACO[ 23 ] and cannot even agree on where and how to measure the STE.…”

“…The ST-segment elevation (STE) myocardial infarction (MI)/non-STEMI (NSTEMI) paradigm has been the central dogma of emergency cardiology for nearly 30 years. [ 1 ] It has been widely accepted as the infallible indication of an acute coronary occlusion (ACO) or near-occlusion that necessitates and benefits from immediate reperfusion. The term STEMI established itself so firmly in our minds, as if the real disorder that we are looking for was an electrocardiogram (ECG) abnormality rather than the ACO itself.…”