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Three Part Question

In [patients presenting to the ED with acute ischemic chest pain], what is the [diagnostic test accuracy of ST-segment elevation] compared to [coronary angiograms] for the [diagnosis of acute coronary occlusion]?

Clinical Scenario

A 55-year-old male with a history of hypertension and hyperlipidemia presents to the emergency department with sudden onset of severe chest pain radiating to his left arm. On physical examination, he is diaphoretic and appears anxious. His initial electrocardiogram (ECG) appears normal. You wonder how accurate the ECG findings are to rule out acute coronary occlusion (ACO).

Search Strategy

Medline 1966-07/24 using PubMed, Cochrane Library (2024), and Embase
[(ST elevation myocardial infarction/diagnosis.mp OR Coronary occlusion/diagnosis.mp) AND (Electrocardiography"[MeSH]) AND (accuracy.mp OR sensitivity.mp OR specificity.mp)] Limit to English language.

Search Outcome

128 studies were identified; one recent systematic review was identified that answered the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
de Alencar Neto JN, et al May 2024 Brazil	Three studies with 23,704 participants that focused on AMI patients and provided data enabling the construction of contingency tables for sensitivity and specificity calculation	Systematic review with meta-analysis	Sensitivity of ST-segment elevation for detecting ACO	43.6% (95% CI: 34.7%–52.9%)	OMI-NOMI paradigm has no standard definition of ACO, hindering replicability of studies; included studies were all retrospective; high heterogeneity
			Specificity of ST-segment elevation	96.5% (95% CI: 91.2%–98.7%)
			Sensitivity of the the OMI-NOMI strategy	78.1% (95% CI: 62.7%–88.3%)
			Specificity of the the OMI-NOMI strategy	94.4% (95% CI: 88.6%–97.3%)

Comment(s)

Rapid diagnosis of acute coronary syndrome is already undergoing a paradigm shift. The low sensitivity of ST-segment elevation (STE) for ACO detection highlights the need to reconsider the reliance solely on STE for diagnosing intervenable coronary occlusions. This STEMI-NSTEMI strategy does identify a subset of occluded coronary arteries that require emergent intervention but excludes many patients that may benefit from emergent catheterization. Given its improved sensitivity while maintaining high specificity, the occluded/non-occluded myocardial infarction (OMI-NOMI) strategy should be considered for clinical practice. This involves recognizing other ECG markers such as hyperacute T waves, terminal QRS distortion, and other newly identified patterns that are indicative of acute occlusion myocardial infarctions that could benefit from emergent revascularization. Future work involves formal acknowledgement of the new paradigm by international cardiology organizations and then uptake by local health systems. Furthermore, there is likely an opportunity to utilize artificial intelligence in ECG interpretation, which has been shown to be promising in retrospective studies.

Clinical Bottom Line

In patients presenting to the ED with acute ischemic chest pain, the current STEMI-NSTEMI paradigm can miss almost half of all patients that could benefit from emergent revascularization of a coronary artery, highlighting the need for a paradigm shift toward creating new definitions, like the OMI-NOMI paradigm.

References

1. de Alencar Neto JN, Scheffer MK, Correia BP, Franchini KG, Felicioni SP, De Marchi MFN. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. Int J Cardiol 2024 May 1;402:131889