Uncovering key predictors of diagnostic inaccuracy in acute coronary syndrome

Introduction Occlusion Myocardial Infarction (OMI) is a new concept in Acute Coronary Syndromes (ACS), challenging the traditional STEMI paradigm. It focuses on detecting acute coronary occlusion through subtle ECG findings to better identify patients needing urgent revascularization. This study evaluates NSTEMI patients with acute OMI, emphasizing cases where this shift is clinically significant. Methods We retrospectively analyzed 336 ACS patients admitted over one year. Patients initially classified as STEMI or NSTEMI/UA were reclassified as OMI or non-OMI ACS based on OMI definition: TIMI flow ≤2 and/or significantly elevated troponin with regional wall motion abnormalities. Patients were grouped as STEMI, NSTEMI-OMI, or NSTEMI-non-OMI. Baseline characteristics, including demographics, comorbidities, and ECG findings, were compared across groups. Results Among 336 ACS patients, 196 were STEMI and 134 were NSTEMI/UA. Of these, 52 were reclassified as NSTEMI-OMI. NSTEMI-OMI patients more frequently had BBB or pacemaker rhythm (23.1% vs. 6.1%; p < 0.001) and a history of coronary disease (30.8% vs. 11.2%; p = 0.002) compared to STEMI patients. No other significant differences in demographics, comorbidities, or ECG characteristics were found. Similarly, no significant differences were observed between NSTEMI-OMI and NSTEMI-non-OMI patients. Discussion: Prior ECG changes and a history of coronary disease may obscure coronary occlusion using STEMI criteria, likely due to baseline ECG abnormalities. Adopting the OMI paradigm could improve early recognition and management by identifying occlusions regardless of STEMI criteria. Advanced tools like AI-driven ECG analysis could enhance detection and support timely revascularization. However, the OMI paradigm faces challenges, including a lack of standardization in ECG interpretation and validation in randomized studies. Conclusion Adopting the OMI paradigm could improve the detection and management of coronary occlusion in patients with challenging ECGs, such as those with BBB, pacemaker rhythm, or prior coronary disease. Further standardization and validation are needed for broader clinical applicability.