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October 1, 2026JACC: Cardiovascular Interventions
Acute Coronary Occlusions in NSTEMI Undergoing Percutaneous Coronary Intervention
Key result
Acute coronary occlusion in NSTEMI is linked to ~2.3-fold higher in-hospital major cardiovascular events.
- adjusted OR 2.26
- 95% CI 2.18-2.34
- P<0.001
- n=1,198,544
JACC: Cardiovascular Interventions published a graphical abstract
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Why the study?
Acute coronary occlusions can occur in patients with NSTEMI without ST-segment elevation criteria, but their incidence, characteristics, and outcomes are not well defined.
Does the presence of acute coronary occlusion in NSTEMI patients worsen in-hospital outcomes compared to NSTEMI without acute coronary occlusion?
Key Points
- To assess the incidence, clinical features, and in-hospital outcomes of acute coronary occlusion in patients presenting with NSTEMI undergoing percutaneous coronary intervention.
- Analyzed 1,198,544 patients undergoing percutaneous coronary intervention in the CathPCI Registry between April 1, 2018, and June 30, 2023.
- Stratified patients into STEMI, NSTEMI with acute coronary occlusion (defined as 100% acute stenosis), and NSTEMI without occlusion, evaluating a composite endpoint of in-hospital stroke, myocardial infarction, or cardiovascular mortality.
- Acute coronary occlusions were present in 11.0% of all patients (15% of those with NSTEMI), with sensitivity analysis including TIMI flow 0/1 raising this to 24.4% of NSTEMI cases.
- NSTEMI patients with occlusion experienced higher rates of cardiogenic shock (3.8% vs 1.9%; P < 0.001), ventricular arrhythmias (2.0% vs 1.3%; P < 0.001), and in-hospital cardiac arrest (2.7% vs 1.6%; P < 0.001) than those without occlusion.
- The primary composite outcome occurred significantly more often in NSTEMI with occlusion than without (adjusted OR: 2.26; 95% CI: 2.18-2.34; P < 0.001), but less often than in STEMI (adjusted OR: 0.54; 95% CI: 0.52-0.56; P < 0.001).
Study Design
Type
Cohort (n=1,198,544)
Multicenter
Yes
Structured PICO
Does the presence of acute coronary occlusion in NSTEMI patients worsen in-hospital outcomes compared to NSTEMI without acute coronary occlusion?
P
Population
1,198,544 patients with STEMI and NSTEMI undergoing percutaneous coronary intervention evaluated for in-hospital outcomes based on the presence of acute coronary occlusion.
E
Exposure
NSTEMI with acute coronary occlusion (NSTEMI-ACO), defined as 100% stenosis deemed acute (or TIMI flow grade 0 or 1 in sensitivity analysis).
C
Comparator
NSTEMI without acute coronary occlusion (NSTEMI-no-ACO) and STEMI (including STEMI equivalents).
O
Outcome
Composite of in-hospital stroke, myocardial infarction, or cardiovascular mortality.composite
Main Result
Odds Ratio: 2.26 (95% CI 2.18–2.34)
p-value: p=<0.001
Acute coronary occlusion is present in a substantial proportion of NSTEMI patients (15-24%) and is associated with significantly worse in-hospital cardiovascular outcomes compared to NSTEMI without occlusion.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
AGAlejandro González VelizInterventional cardiologist, Institute of Cardiology and Cardiovascular Surgery
“The ECG remains essential, but it must be interpreted alongside the clinical presentation. Persistent or refractory ischemic symptoms, subtle ECG abnormalities, hyperacute T waves, and patterns suggesting posterior myocardial infarction should prompt careful reassessment. Additional ECG leads may be appropriate when clinically indicated. Importantly, this observational study demonstrates an association between acute coronary occlusion and worse in hospital outcomes; it does not establish that immediate reperfusion improves outcomes in every NSTEMI patient with an occluded artery. The optimal management strategy requires further investigation.”
“We report a substantial 15% incidence of NSTEMI-ACO when using a definition of 100% ACO, but this rose to 24% when including culprit arteries with TIMI flow grade 0 to 1, which is concordant with prior reported frequencies of 20% to 25%. Although the 100% ACO definition is potentially more specific, it likely underestimates the true prevalence of ACO because of the dynamic nature of ACO.”
“the adjusted odds ratio of 0.54 vs. STEMI is not reassuring. These patients had far more events than those with NSTEMI-no-ACO, and this invites comment on some biases. Entry into this cohort required reaching the catheterization laboratory.”
Implication
NSTEMI with ACO carries higher in-hospital MACE risk; leaves open whether ECG or AI tools should prompt earlier angiography.
Abstract
BACKGROUND Patients may present with acute coronary occlusions (ACOs) without manifesting electrocardiographic criteria for ST-segment elevation myocardial infarction (STEMI). OBJECTIVES The aim of this study was to examine the incidence, clinical characteristics, and in-hospital outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) with ACO. METHODS The study included patients with STEMI and NSTEMI in the CathPCI Registry who underwent percutaneous coronary intervention between April 1, 2018, and June 30, 2023. ACO was defined as 100% stenosis deemed acute. The cohort was stratified into STEMI (including STEMI equivalents), NSTEMI-ACO, and NSTEMI-no-ACO. The primary outcome was a composite of in-hospital stroke, myocardial infarction, or cardiovascular mortality. A sensitivity analysis with ACO defined as 100% acute occlusion or TIMI flow grade 0 or 1 in the culprit artery was performed. RESULTS Of 1,198,544 patients, 26.1% had STEMI, 11.0% had NSTEMI-ACO (15% of whom had NSTEMI), and 62.9% had NSTEMI-no-ACO. Compared with those with NSTEMI-no-ACO, NSTEMI-ACO patients had more cardiogenic shock (9.0% STEMI vs 3.8% NSTEMI-ACO vs 1.9% NSTEMI-no-ACO; P < 0.001), ventricular arrhythmias (4.9% vs 2.0% vs 1.3%; P < 0.001), and in-hospital cardiac arrest (6.1% vs 2.7% vs 1.6%; P < 0.001). Patients with NSTEMI-ACO had a higher risk for the primary composite compared with those with NSTEMI-no-ACO (adjusted OR: 2.26; 95% CI: 2.18-2.34; P < 0.001) but a lower risk compared with those with STEMI (adjusted OR: 0.54; 95% CI: 0.52-0.56; P < 0.001). Using a definition of ACO including TIMI flow grade 0 or 1, NSTEMI-ACO accounted for 216,054 presentations (24.4% of NSTEMI). In-hospital outcomes were similarly worse compared with NSTEMI-no-ACO and better compared with STEMI. CONCLUSIONS ACO occurs in a substantial proportion of patients with NSTEMI and is associated with worse in-hospital outcomes relative to those with NSTEMI-no-ACO. Further studies of early identification and reperfusion practices for NSTEMI-ACO are warranted.
Discussion
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Cite This Study
Kherallah et al. (2026) conducted a cohort in NSTEMI and STEMI (n=1,198,544). Acute coronary occlusion (NSTEMI-ACO) vs. NSTEMI without acute coronary occlusion (NSTEMI-no-ACO) was evaluated on Composite of in-hospital stroke, myocardial infarction, or cardiovascular mortality (adjusted OR 2.26, 95% CI 2.18-2.34, p=<0.001). NSTEMI with acute coronary occlusion was associated with a higher risk for the primary composite of in-hospital stroke, MI, or CV mortality compared to NSTEMI without occlusion (OR 2.26; 95% CI 2.18-2.34; P<0.001).