Missed occlusions: diagnostic accuracy of ECG STEMI criteria for identifying occlusive myocardial infarction. A systematic review and meta-analysis

The ECG-STEMI criteria are widely used to identify Acute Myocardial Infarction (AMI) patients who need urgent revascularization. However, recent evidence shows that up to one-third of Occlusive Myocardial Infarctions (OMIs) may go undetected using these criteria. While still a cornerstone of current triage protocols, doubts remain about their diagnostic accuracy, particularly their sensitivity in detecting OMI. This systematic review and meta-analysis aimed to assess the diagnostic accuracy of ECG-STEMI criteria in identifying patients with OMI. A comprehensive search of MEDLINE, EMBASE, and Scopus was conducted up to February 2024. Included studies enrolled patients with confirmed AMI and provided data to construct 2×2 tables comparing ECG-STEMI results (index test) with angiographic findings (reference standard) for OMI. Risk of bias was assessed using QUADAS-2. We calculated pooled sensitivity, specificity, diagnostic odds ratio (DOR), and generated SROC curves using random-effects models. Nine studies (11,757 patients) were included. ECG-STEMI criteria showed a pooled sensitivity of 0.635 (95% CI: 0.549–0.713) and specificity of 0.780 (95% CI: 0.645–0.873). The DOR was 5.94 (95% CI: 3.81–9.27), with an AUC of 0.752 (95% CI: 0.714–0.795). Definitions of OMI varied across studies; composite definitions yielded higher specificity and DOR but lower sensitivity than angiographic definitions alone. ECG-STEMI criteria offer high specificity but only moderate sensitivity for detecting OMI, potentially missing one-third of patients needing urgent care. These criteria are more reliable for confirming rather than excluding OMI. Diagnostic accuracy depends on how OMI is defined, highlighting the need for a standardized definition to better assess both current and emerging ECG criteria.