Missing occlusions: Quality gaps for ED patients with occlusion MI

Background: ST-elevation Myocardial Infarction (STEMI) guidelines encourage monitoring of false positives (Code STEMI without culprit) but ignore false negatives (non-STEMI with occlusion myocardial infarction [OMI]). We evaluated the hospital course of emergency department (ED) patientswith acute coronary syndrome (ACS) using STEMI vs OMI paradigms. Methods: This retrospective chart review examined all ACS patients admitted through two academic EDs, from June 2021 to May 2022, categorized as 1) OMI (acute culprit lesion with TIMI 0-2 flow, or acute culprit lesion with TIMI 3 flow and peak troponin I > 10,000 ng/L; or, if no angiogram, peak troponin > 10,000 ng/L with new regional wall motion abnormality), 2) NOMI (Non-OMI, i.e. MI without OMI) or 3) MIRO (MI ruled out: no troponin elevation). Patients were stratified by admission for STEMI. Initial ECGs were reviewed for automated interpretation of STEMI, and admission/discharge diagnoses were compared. Results: Among 382 patients, therewere 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIswere admitted as STEMI: 60.0% had STEMI on ECG, and median door-to-cath time was 103 min (IQR 71-149). But 59.6% of OMIs were not admitted as STEMI: 1.3% had STEMI on ECG (p < 0.001) and median door-to-cath time was 1712 min (IQR 1043-3960; p < 0.001). While 13.9% of STEMIs were false positive and had a different discharge diagnosis, 32.0% of Non-STEMIs had OMI but were still discharged as Non-STEMI. Conclusions: STEMI criteria miss a majority of OMI, and discharge diagnoses highlight false positive STEMI but never false negative STEMI. The OMI paradigm reveals quality gaps and opportunities for improvement. (c) 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Automated summary

There are differences in the hospital course of patients with acute coronary syndrome using STEMI and OMI paradigms in the emergency department. STEMI criteria miss a majority of OMI, while the OMI paradigm reveals opportunities for improvement.