Rebellion21: Time to Evolve – Redefining Coronary Ischemia – The OMI/NOMI Paradigm via Tarlan Hedayati, MD

Oct 03, 21
Rebellion21: Time to Evolve – Redefining Coronary Ischemia – The OMI/NOMI Paradigm via Tarlan Hedayati, MD

In this 14-minute presentation from Rebellion in EM 2021, Dr. Tarlan Hedayati, MD discusses the shift from the paradigm of STEMI/NSTEMI to OMI/NOMI.


Tarlan Hedayati, MD
Emergency Medicine
Cook County Health
Twitter: @HedayatiMD

Objectives

1. Review the history of STEMI/NSTEMI designation and current OMI/NOMI paradigm
2. Discuss the risks of management decisions based on the STEMi/NSTEMI designation
2. Review the evidence regarding advantages of the OMI/NOMI paradigm

Redefining Coronary Ischemia (OMI vs NOMI)

  • ST-Elevation Myocardial Infarction (STEMI) doesn’t always equal occlusion myocardial infarction (OMI)
  • OMI doesn’t always manifest as ST-elevation on the ECG (i.e. hyperacute T waves, etc…)
  • 2014 AHA/ACC guideline (Amsterdam et al, Circ 2014) for the management of patients with NSTEMI indicated that there are some NSTEMI patients that would benefit from:
    • Immediate invasive strategy (i.e. <2hrs)
      • Refractory Angina
      • Recurrent Angina
      • Sustained VT/VF
      • Hemodynamically Unstable
    • Early invasive strategy (i.e. 2 – 24hrs)
      • Dynamic ECG (i.e. New ST depression)
      • Rising Troponin
    • Delayed invasive strategy (i.e. 24 – 72hrs)
      • DM
      • CKD
      • EF <40%
      • CABG/PCI <6mo
      • Post-MI pain
    • Systematic Review and Meta-Analysis (Khan et al, Eur Heart J, 2017):
      • 7 studies with 40,777 patients with NSTEMI
      • 5% had an occluded culprit artery
      • These patients had increased risk of increased short-term and long-term mortality
    • Comparison of STEMI/NSTEMI vs OMI/NOMI (Meyers et al, J Emerg Med, 2021)

      • 467 patients
      • 448 cardiac catheterization
      • 108 had OMI
      • 67 had STEMI
      • 41 patients (38%) didn’t not meet STEMI criteria but had OMI
      • Median time to cath:
      • STEMI (+) OMI: 41min
      • STEMI (-) OMI: 437min
  • Retrospective Case-Control Study (Meyers et al, IJC Heart and Vasc, 2021):
    • 808 patients with suspected acute coronary syndrome
    • 49% had acute myocardial infarction
      • 33% OMI
      • 16% NOMI
    • 265 patients with OMI
      • 108 patients met STEMI criteria
      • Sensitivity = 41%
    • OMI ECG Criteria not Meeting STEMI Criteria:
      • Subtle STE: 83%
      • Reciprocal ST depression and/or negative hyperacute T waves: 82%
      • Terminal QRS distortion: 53%
      • Inferior STE and any STD/TWI in aVL: 50%
      • Hyperacute T waves: 49%
      • STD maximal in V1 – V4: 45%
      • Acute pathologic Q waves: 47%
    • DIFOCCULT Trial (Aslanger et al, IJC Heart and Vasc, 2020):
      • 1000 STEMI patients
      • 1000 NSTEMI patients
      • 1000 control patients
      • Of the 1000 NSTEMI patients, 282 (28.2%) were reclassified as OMI
      • Reclassified NSTEMI patients were more like STEMI patients than non-reclassified NSTEMI patients
        • Acute Coronary Occlusion:
          • STEMI: 85%
          • Re-Classified NSTEMI: 61%
          • Non-Re-Classified NSTEMI: 25%
        • In-Hospital Mortality:
          • STEMI: 8%
          • Re-Classified NSTEMI: 5%
          • Non-Re-Classified NSTEMI: 2%
        • Long-Term Mortality:
          • STEMI: 14%
          • Re-Classified NSTEMI: 11%
          • Non-Re-Classified NSTEMI: 4%
        • OMI/NOMI is not perfect and still missed 17% of acute coronary occlusions, but significantly better than STEMI/NSTEMI criteria

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post Rebellion21: Time to Evolve – Redefining Coronary Ischemia – The OMI/NOMI Paradigm via Tarlan Hedayati, MD appeared first on REBEL EM - Emergency Medicine Blog.

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