Missing occlusions: Quality gaps for ED patients with occlusion MI.

Acute coronary syndrome Electrocardiogram Occlusion myocardial infarction ST-segment myocardial infarction

Journal

The American journal of emergency medicine
ISSN: 1532-8171
Titre abrégé: Am J Emerg Med
Pays: United States
ID NLM: 8309942

Informations de publication

Date de publication:
Nov 2023
Historique:
received: 01 05 2023
revised: 17 07 2023
accepted: 11 08 2023
pubmed: 24 8 2023
medline: 24 8 2023
entrez: 23 8 2023
Statut: ppublish

Résumé

ST-elevation Myocardial Infarction (STEMI) guidelines encourage monitoring of false positives (Code STEMI without culprit) but ignore false negatives (non-STEMI with occlusion myocardial infarction [OMI]). We evaluated the hospital course of emergency department (ED) patients with acute coronary syndrome (ACS) using STEMI vs OMI paradigms. This retrospective chart review examined all ACS patients admitted through two academic EDs, from June 2021 to May 2022, categorized as 1) OMI (acute culprit lesion with TIMI 0-2 flow, or acute culprit lesion with TIMI 3 flow and peak troponin I >10,000 ng/L; or, if no angiogram, peak troponin >10,000 ng/L with new regional wall motion abnormality), 2) NOMI (Non-OMI, i.e. MI without OMI) or 3) MIRO (MI ruled out: no troponin elevation). Patients were stratified by admission for STEMI. Initial ECGs were reviewed for automated interpretation of "STEMI", and admission/discharge diagnoses were compared. Among 382 patients, there were 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIs were admitted as STEMI: 60.0% had "STEMI" on ECG, and median door-to-cath time was 103 min (IQR 71-149). But 59.6% of OMIs were not admitted as STEMI: 1.3% had "STEMI" on ECG (p < 0.001) and median door-to-cath time was 1712 min (IQR 1043-3960; p < 0.001). While 13.9% of STEMIs were false positive and had a different discharge diagnosis, 32.0% of Non-STEMIs had OMI but were still discharged as "Non-STEMI." STEMI criteria miss a majority of OMI, and discharge diagnoses highlight false positive STEMI but never false negative STEMI. The OMI paradigm reveals quality gaps and opportunities for improvement.

Sections du résumé

BACKGROUND BACKGROUND
ST-elevation Myocardial Infarction (STEMI) guidelines encourage monitoring of false positives (Code STEMI without culprit) but ignore false negatives (non-STEMI with occlusion myocardial infarction [OMI]). We evaluated the hospital course of emergency department (ED) patients with acute coronary syndrome (ACS) using STEMI vs OMI paradigms.
METHODS METHODS
This retrospective chart review examined all ACS patients admitted through two academic EDs, from June 2021 to May 2022, categorized as 1) OMI (acute culprit lesion with TIMI 0-2 flow, or acute culprit lesion with TIMI 3 flow and peak troponin I >10,000 ng/L; or, if no angiogram, peak troponin >10,000 ng/L with new regional wall motion abnormality), 2) NOMI (Non-OMI, i.e. MI without OMI) or 3) MIRO (MI ruled out: no troponin elevation). Patients were stratified by admission for STEMI. Initial ECGs were reviewed for automated interpretation of "STEMI", and admission/discharge diagnoses were compared.
RESULTS RESULTS
Among 382 patients, there were 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIs were admitted as STEMI: 60.0% had "STEMI" on ECG, and median door-to-cath time was 103 min (IQR 71-149). But 59.6% of OMIs were not admitted as STEMI: 1.3% had "STEMI" on ECG (p < 0.001) and median door-to-cath time was 1712 min (IQR 1043-3960; p < 0.001). While 13.9% of STEMIs were false positive and had a different discharge diagnosis, 32.0% of Non-STEMIs had OMI but were still discharged as "Non-STEMI."
CONCLUSIONS CONCLUSIONS
STEMI criteria miss a majority of OMI, and discharge diagnoses highlight false positive STEMI but never false negative STEMI. The OMI paradigm reveals quality gaps and opportunities for improvement.

Identifiants

DOI: 10.1016/j.ajem.2023.08.022 PMID: 37611526
pubmed: 37611526
pii: S0735-6757(23)00438-2
doi: 10.1016/j.ajem.2023.08.022
pii:
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

47-54

Informations de copyright

Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.

Déclaration de conflit d'intérêts

Declaration of Competing Interest Dr. Meyers has been a paid consultant to Rapid AI and Baxter/Veritas and holds stocks from Powerful Medical. Dr. Smith reported personal fees from Cardiologs, HEARTBEAM, Rapid AI, and Baxter/Veritas, and holds stocks from Powerful Medical and Pulse AI.

Auteurs

Jesse T T McLaren (JTT)

Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Emergency Department, University Health Network, Toronto, Ontario, Canada. Electronic address: jesse.mclaren@gmail.com.

Mazen El-Baba (M)

Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

Varunaavee Sivashanmugathas (V)

Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. Electronic address: varunaavee.sivashanmugathas@mail.utoronto.ca.

H Pendell Meyers (HP)

Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA.

Stephen W Smith (SW)

Department of Emergency Medicine, Hennepin County Medical Centre and University of Minnesota, Minneapolis, MN, USA. Electronic address: smith253@umn.edu.

Lucas B Chartier (LB)

Emergency Department, University Health Network, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada. Electronic address: lucas.chartier@uhn.ca.

Classifications MeSH