The Dangers of the OMI

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Meyers, H. P. et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Medicine 60, 273–284 (2021).

Background

For the past 20-30 years, we have been using the words STEMI and NSTEMI to help us determine who needs to go to the cardiac cath lab for reperfusion. Over this time period, we have also identified that not all ischemic disease is captured in the STEMI group. This paper is one of a few written by Pendell Meyers developing support for a paradigm shift from STEMI vs. NSTEMI to OMI vs. NOMI in order to capture the group of patients that have occlusive disease but no STEMI on EKG. The goal of this study was to look at the differences/similarities between STEMI (+) OMI and STEMI (-) OMI with the hypothesis that despite similar characteristics, time to catheterization is different.

Methods

This was a retrospective review of prospectively collected data in the DOMI ARIGATO trial. Data was collected in a suburban academic hospital and included patients that had presumed ACS (patients admitted to the cardiology service with plan for catheterization and patients that had interventional cardiology engaged in the ED). Primary outcomes were troponin peak and time from presentation to catheterization.

Results

Of the 467 patients included in the study, 108 met OMI criteria. 38% of these patients did not have STEMI on EKG. They found that peak troponin levels for STEMI (+) OMI and STEMI (-) OMI (5.36 ng/mL and 4.44 ng/mL) vs. the group with no occlusion (0.12 ng/mL) was statistically significant. Time to catheterization for STEMI (+) OMI vs. STEMI (-) OMI was also significantly different with times being 41 min for the STEMI group and 437 min for the non-STEMI group.

Takeaways/Impact for Our Patients

Patients that present to the ED with symptoms concerning for ACS may benefit from early catheterization despite not having a STEMI on EKG. Patient with occlusive disease have similar presentations, similar peak troponin levels, and similar outcomes (wall motion abnormalities) despite about 40% not having STEMI on EKG. This paper supports the idea that switching our mindset from STEMI vs. NSTEMI to OMI vs. NOMI may help us get patients to the cath lab sooner. This paper was limited by no follow up data so further research into how this affects patient outcomes is warranted.

Authorship

Written by Payton Thode, MD, PGY-3 University of Cincinnati Department of Emergency Medicine

Editing and Posting - Jeffery Hill, MD MEd