DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study)

Abstract

Background: Although ST-segment elevation (STE) has been used synonymously with acute coronary occlusion (ACO), current STE criteria miss nearly one-third of ACO and result in a substantial amount of false catheterization laboratory activations. As many other electrocardiographic (ECG) findings can reliably indicate ACO, we sought whether a new ACO/non-ACO myocardial infarction (MI) paradigm would result in better identification of the patients who need acute reperfusion therapy.

Methods: A total of 3000 patients were enrolled in STEMI, non-STEMI and control groups. All ECGs were reviewed by two cardiologists, blinded to any outcomes, for the current STEMI criteria and other subtle signs. A combined ACO endpoint was composed of peak troponin level, troponin rise within the first 24 h and angiographic appearance. The dead or alive status was checked from hospital records and from the electronic national database.

Results: In non-STEMI group, 28.2% of the patients were re-classified by the ECG reviewers as having ACO. This subgroup had a higher frequency of ACO, myocardial damage, and both in-hospital and long-term mortality compared to non-STEMI group. A prospective ACOMI/non-ACOMI approach to the ECG had superior diagnostic accuracy compared to the STE/non-STEMI approach in the prediction of ACO and long-term mortality. In Cox-regression analysis early intervention in patients with non-ACO-predicting ECGs was associated with a higher long-term mortality.

Conclusions: We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI. (DIFOCCULT study; ClinicalTrials.gov number, NCT04022668.).

Keywords: ACO, acute coronary occlusion; CABG, coronary artery by-pass grafting; Coronary occlusion; ECG, electrocardiogram; Electrocardiogram; GRACE, The Global Registry of Acute Coronary Events; MI, myocardial infarction; Myocardial infarction; PCI, percutaneous coronary intervention; Percutaneous coronary intervention; ST-segment elevation; STE, ST-segment elevation.

Fig. 1

Cumulative survival according to presentation groups. Kaplan-Meier estimates of the cumulative survival according to groups are presented, first non-ST-elevation myocardial infarction (STEMI) group as a whole (Panel A), and then as divided into two according to the presence of an ACO-predicting ECG (non-STEMI-A) or not (non-STEMI-B) (Panel B).