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) patients with 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, there were 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIs were 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.