Key result
Guideline very-high-risk criteria miss ~42% of occlusion MIs and rarely achieve timely PCI.
Why the study?
Guidelines recommend immediate invasive management for NSTE-ACS patients meeting very high-risk criteria, but whether these criteria identify occlusion myocardial infarction and expedite reperfusion is uncertain.
Do ESC and ACC/AHA very high-risk criteria accurately identify occlusion myocardial infarction and expedite reperfusion in patients with NSTE-ACS?
Observational (n=2,979)
Do ESC and ACC/AHA very high-risk criteria accurately identify occlusion myocardial infarction and expedite reperfusion in patients with NSTE-ACS?
Current ESC and ACC/AHA very high-risk criteria have limited sensitivity for identifying occlusion myocardial infarction in NSTE-ACS patients and rarely lead to the guideline-recommended immediate PCI within 2 hours.
Current very-high-risk criteria miss most OMI and rarely enable timely PCI; challenges guideline recommendations for immediate invasive NSTE-ACS management.
AIMS: Guidelines recommend immediate invasive management for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients meeting very high-risk (VHR) criteria. Whether these criteria identify occlusion myocardial infarction (OMI) and expedite reperfusion is uncertain. METHODS AND RESULTS: This post-hoc analysis included 2979 NSTE-ACS patients undergoing percutaneous coronary intervention (PCI) in the MATRIX programme with available culprit-lesion flow. OMI was defined as culprit-vessel TIMI flow 0-1. We evaluated European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) VHR criteria for OMI detection and time from first medical contact (FMC) to PCI. OMI occurred in 592 patients (19.9%). At least one VHR criterion was present in 52.9% according to ESC and 14.1% according to ACC/AHA definitions. Among patients with OMI, only 58.1% fulfilled ESC and 24.1% ACC/AHA criteria. Median FMC-to-PCI time was shorter in patients fulfilling ESC criteria (27.0 vs. 40.5 h) or ACC/AHA VHR criteria (12.2 vs. 69.9 h; both P < 0.001). Nevertheless, PCI within 2 h occurred in only 2.6% and 7.7% of patients meeting ESC and ACC/AHA criteria, respectively, and in 3.6% of patients with OMI. Even among OMI patients fulfilling VHR criteria, timely reperfusion within 2 h occurred only 4.7% and 9.9%. CONCLUSION: Guideline-directed VHR criteria had limited sensitivity for OMI and rarely translated into guideline-recommended immediate PCI. Current NSTE-ACS classification and triage strategies require reconsideration to improve recognition and timely reperfusion of acute coronary occlusion.
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Milzi et al. (2026) conducted an observational in Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) (n=2,979). Guideline-directed very-high-risk (VHR) criteria (ESC and ACC/AHA) vs. Absence of VHR criteria was evaluated on Median time from first medical contact to PCI (ESC criteria present vs. absent, in hours) (p=<0.001). Guideline-directed very-high-risk criteria had limited sensitivity for occlusion myocardial infarction (58.1% for ESC, 24.1% for ACC/AHA) and rarely translated to PCI within 2 hours.
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