Beyond STEMI-NSTEMI Paradigm: Dante Pazzanese's Proposal for Occlusion Myocardial Infarction Diagnosis

Abstract

Although the existing framework for classifying acute myocardial infarction (AMI) into STEMI and NSTEMI has been beneficial, it is now considered to be falling short in addressing the complexity of acute coronary syndromes. The study aims to scrutinize the current STEMI-NSTEMI paradigm and advocate for a more nuanced framework, termed as occlusion myocardial infarction (OMI) and non-occlusion myocardial infarction (NOMI), for a more accurate diagnosis and management of AMI. A comprehensive analysis of existing medical literature was conducted, with a focus on the limitations of the STEMI-NSTEMI model. The study also outlines a new diagnostic approach for patients presenting with chest pain in emergency settings. The traditional STEMI-NSTEMI model falls short in diagnostic precision and effective treatment, especially in identifying acute coronary artery occlusions. The OMI-NOMI framework offers a more anatomically and physiologically accurate model, backed by a wealth of clinical research and expert opinion. It underscores the need for quick ECG assessments and immediate reperfusion therapies for suspected OMI cases, aiming to improve patient outcomes. The OMI-NOMI framework offers a new avenue for future research and clinical application. It advocates for a more comprehensive understanding of the underlying mechanisms of acute coronary syndromes, leading to individualized treatment plans. This novel approach is expected to ignite further scholarly debate and research, particularly in the Brazilian cardiology sector, with the goal of enhancing diagnostic accuracy and treatment effectiveness in AMI patients.

Figura 1. Ondas T hiperagudas; eletrocardiograma a 25 mm/s mostrando uma onda T hiperaguda nas derivações V2-V4.

Figura 2. Sinal sutil de De Winter; eletrocardiograma a 25 mm/s mostrando o padrão de De Winter, caracterizado pela depressão do segmento ST no ponto J nas derivações V1-V2 a V6, seguida por um ST ascendente e uma curva T positiva, simétrica, hiperaguda.

Figura 3. Elevação do segmento ST na parede ântero-apical; eletrocardiograma mostrando uma sutil elevação do segmento ST de aproximadamente 1 mm nas derivações V1-V4, o que não preenche o critério estabelecido pela Definição Universal de Infarto do Miocárdio; o uso da calculadora de quatro variáveis indicou oclusão coronariana aguda (OCA); a angiografia coronariana subsequente confirmou oclusão da artéria descendente anterior esquerda.

Figura 4. Indicadores eletrocardiográficos chave para oclusão coronariana aguda.

Figura 5. Fluxograma ilustrando a abordagem atual para o diagnóstico de infarto agudo do miocárdio; essa tem sido o pilar para o tratamento de muitos pacientes em várias áreas médicas; o algoritmo retrata as limitações de se confiar somente no eletrocardiograma e nos níveis de troponina.

Figura 6. Algoritmo de decisão proposto para o manejo de dor torácica no departamento de emergência; o fluxograma ilustra uma abordagem abrangente para a avaliação e o manejo de pacientes apresentando dor torácica no departamento de emergência. O algoritmo incorpora critérios diagnósticos tradicionais bem como critérios detalhados, visando melhorar a identificação e o tratamento de Oclusão Coronariana Aguda (OCA); etapas chave incluem avaliação clínica inicial, rápida avaliação por Eletrocardiograma (ECG), e consideração tanto de Elevação do Segmento ST (EST) como outros sinais eletrocardiográficos. O algoritmo também considera a possibilidade de casos falso-negativos de OCA, enfatizando a importância de monitorar dor torácica ou alterações dinâmicas no ECG como indicadores de terapia de reperfusão imediata. Importante notar que, enquanto esse algoritmo proposto oferece um potencial avanço no manejo de dor torácica, sua implementação em uma escala nacional, particularmente no Sistema Único de Saúde no Brasil, pode aumentar o número de intervenções coronárias percutâneas. Portanto, as implicações logísticas e econômicas dessa proposta devem ser cuidadosamente consideradas, e posteriormente validadas por ensaios clínicos randomizados antes de sua ampla adoção; DST: depressão do segmento ST.

Figure 1. Hyperacute T waves; electrocardiogram at 25 mm/s showing a hyperacute T-wave in leads V2-V4.

Figure 2. Subtle De Winter sign; electrocardiogram at 25 mm/s displaying the De Winter pattern, characterized by ST-segment depression at the J point in leads V1-V2 to V6, followed by an upsloping ST segment and a high, symmetrical, positive hyperacute T wave.

Figure 3. Subtle ST segment elevation in anteroapical wall; electrocardiogram displaying a subtle STE of approximately 1 mm in V1-V4, which does not fulfil the criteria set by the Universal Definition of Myocardial Infarction. The use of the 4-variable calculator indicated Occlusion Myocardial Infarction (OMI). Subsequent coronary angiography confirmed occlusion of the left anterior descending artery.

Figure 4. Key electrocardiographic indicators for occlusion myocardial infarction.

Figure 5. Flowchart illustrating the current approach for acute myocardial infarction diagnosis; this has been the cornerstone for the treatment of numerous patients across various medical disciplines; the algorithm addresses the limitations of relying solely on electrocardiogram and troponin test results.

Figure 6. Proposed decision algorithm for managing chest pain in the emergency department. This flowchart outlines a comprehensive approach for the evaluation and management of patients presenting with chest pain in the emergency department. The algorithm incorporates both traditional and nuanced diagnostic criteria, aiming to improve the identification and treatment of Occlusion Myocardial Infarction (OMI). Key steps include initial clinical assessment, rapid electrocardiogram (ECG) evaluation, and consideration of both ST-segment elevation (STE) and other ECG signs. The algorithm also accounts for the possibility of false-negative OMI cases, emphasizing the importance of monitoring for refractory chest pain or dynamic changes in ECG as indicators for immediate reperfusion therapy. It is important to note that while this proposed algorithm offers a potential advancement in the management of chest pain, its implementation on a national scale, particularly within Brazil's Universal Healthcare System, may lead to an increase in the number of primary percutaneous coronary interventions. Therefore, the logistics and economic implications of this proposal should be carefully considered, and further validated through randomized controlled trials before widespread adoption.