Presenter: Dr. Nick Byers (iFMEM R2)
Host: Dr. Colin Rouse
Article:
Research question/PICOD
- Question:
- Does shifting from a STEMI/NSTEMI paradigm to a new approach (ACO-MI/ non-ACO-MI) result in better identification of the patients who need acute reperfusion therapy?
- Population:
- Adult ED patients with ACS Symptoms
- Intervention/Comparison:
- STEMI/NSTEMI vs ACOMI/NACOMI
- Outcome:
- Composite ACO defined as one of:
- A) Total occlusion or presence of culprit lesion on angiography with a peak troponin I level equal to or greater than 1.0 ng/mL plus an at least 20% rise within 24 h
- B) A highly elevated peak troponin (greater than 5.0 ng/mL), which was shown to be correlated with ACO
- C) Cardiac arrest before any troponin rise has been documented with supporting clinical evidence of possible ACO
- All cause in hospital mortality
- All cause long term mortality
- Composite ACO defined as one of:
- Secondary Outcomes:
- Time from ECG to coronary angioplasty or CABG
- The sensitivity and specificity of current criteria in diagnosing ACO
- The sensitivity and specificity of ECG without ST-segment elevation to diagnose ACO (accuracy of ECG interpretation of acute coronary occlusion without STEMI criteria)
- The specificity of ECG with STEMI criteria (correct ECG interpretation of false positive STEMI criteria)
- The sensitivity of ECG with STEMI criteria (correct ECG interpretation of false negative STEMI criteria)
- The outcome according to ECG subclassifications (outcomes of the patients who are labeled as STEMI and the patients who are labeled as having NSTEMI but have acute coronary occlusion)
- Design:
- Single center, retrospective case-control study in Turkey
Results
Authors conclusions
“We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI”
Discussion at Journal Club
Strengths
- 3000 patients included, 1000 per arm
- Reviewers were blinded, disagreements were resolved by a 3rd independent reviewer
- EKGs were reviewed again 3 months later to decrease inter-observer variability
- Consecutive patients with an initial diagnosis of MI (i.e. not a convenience sample)
- All patients received guideline-recommended medical treatment
- There were documented criteria of ECG findings to classify the ECGs
Weakness
- This was a retrospective study and at a single centre.
- When troponins were taken was not controlled for/accounted for in any way
- Control group age, medical comorbidities, and cardiac risk factors were much less
- Their results suggest 17% of patients in N-ACOMI (N-STEMI Subgroup B) with angiographic ACO were missed (slide 16 results)
- Study wasn’t powered enough to indicate modest benefit of early intervention over late
- Extrapolating results to the real world may be difficult because ecg interpretation
Bottom line/suggested change to practice/actions
- This single center retrospective chart review suggests that considering coronary occlusion vs. just ST elevation on ekg decreases long-term mortality, and has a better sensitivity, specificity, PPV, and NPV.
- This could be a great way of getting patients better access to PCI for occlusive lesions, though inter-operator variability and time constraints are likely to be difficult to implement