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)

Cite this article as: Salim Rezaie, "Rebellion21: Time to Evolve – Redefining Coronary Ischemia – The OMI/NOMI Paradigm via Tarlan Hedayati, MD", REBEL EM blog, October 3, 2021. Available at: https://rebelem.com/rebellion21-time-to-evolve-redefining-coronary-ischemia-the-omi-nomi-paradigm-via-tarlan-hedayati-md/.
The following two tabs change content below.

Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM

Like this article?

Share on facebook
Share on Facebook
Share on twitter
Share on Twitter
Share on linkedin
Share on Linkdin
Share on email
Share via Email

Want to support rebelem?

Leave a Comment

Time limit is exhausted. Please reload CAPTCHA.

Sponsored

0