From ST-Segment Elevation MI to Occlusion MI: The New Paradigm Shift in Acute Myocardial Infarction

Abstract

A generation ago thrombolytic therapy led to a paradigm shift in myocardial infarction (MI), from Q-wave/non-Q-wave to ST-segment elevation MI (STEMI) vs non-STEMI. Using STE on the electrocardiogram (ECG) as a surrogate marker for acute coronary occlusion (ACO) allowed for rapid diagnosis and treatment. But the vast research catalyzed by the STEMI paradigm has revealed increasing anomalies: 25% of "non-STEMI" have ACO with delayed reperfusion and higher mortality. Studying these limitations has given rise to the occlusion MI (OMI) paradigm, based on the presence or absence of ACO in the patient rather than STE on ECG. The OMI paradigm shift harnesses advanced ECG interpretation aided by artificial intelligence, complementary bedside echocardiography and advanced imaging, and clinical signs of refractory ischemia, and offers the next opportunity to transform emergency cardiology and improve patient care. This State-of-the-Art Review examines the paradigm shifts from Q wave to STEMI to OMI.

Keywords: ST-segment elevation myocardial infarction; acute myocardial infarction; electrocardiogram; occlusion myocardial infarction.

Graphical abstract

Figure 1

The Paradigm Shifts From Q-Wave to ST-Segment Elevation to Occlusion MI Myocardial infarction paradigm evolution reflects Thomas Kuhn's concept of scientific progress, emphasizing the cyclical nature of normal science leading to the discovery of anomalies and then crises that lead to paradigm shifts. Thrombolytic therapy led to the STEMI paradigm, which replaced the previous Q-wave paradigm. As understanding and technology advanced, anomalies within the STEMI paradigm were recognized, inducing a crisis in diagnostic accuracy and treatment effectiveness. This crisis has given rise to the OMI paradigm, challenging the STEMI/non-STEMI dichotomy. MI = myocardial infarction; OMI = occlusion myocardial infarction; STEMI = ST-segment elevation myocardial infarction.

Figure 2

Incorporation Bias Incorporation bias reflects a critical error in the diagnostic methodology, where the index test, which is intended for examination, is mirrored by the reference test, in whole or in part. In the context of myocardial infarction, such bias skews the diagnostic framework, obscuring false negative results and perpetuating the “no-false negative paradox” within the STEMI paradigm. Abbreviation as in Figure 1.

Figure 3

The STEMI/Non-STEMI False Dichotomy STEMI criteria are supposed to differentiate patients with ACO from those without. But up to 25% of code STEMI have No ACO: these are appropriately termed false positives, receive a different discharge diagnosis, and are identified as a quality improvement issue. But at least 25% of “Non-STEMI” Have ACO on delayed angiography, with higher mortality. These should be recognized as false negative STEMI and identified as a quality improvement issue, but instead they are still diagnosed as “Non-STEMI.” This is what we call the “no false negative paradox”: In the STEMI paradigm, there cannot be a false negative diagnosis. ACO = acute coronary occlusion; ECG = electrocardiogram; other abbreviation as in Figure 1.

Figure 4

Occlusion MI Paradigm The OMI paradigm classifies MI by the presence or absence of occlusion in the patient. As with other paradigm shifts, this incorporates the previous paradigm (eg, STEMI(+)OMI) while providing evidence-based advances for STEMI(−)OMI that not only add to ECG interpretation but change the diagnostic focus from ECG to patient. Abbreviations as in Figures 1 and 3.

Central Illustration

From ST-Segment Elevation MI to occlusion MI The new paradigm shift in acute myocardial infarction. AI = artificial intelligence; CT = computed tomography; NOMI = nonocclusive myocardial infarction; other abbreviations as in Figure 1.