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Acute Coronary Syndrome Related Articles & Guidelines

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 Case Example of OMI with Ventricular Pacing 

Occlusive Myocardial Infarction in Pacing Rhythm Algorithm

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DIFOCCULT Study & Algorithm: 
This study compared OMI/non-OMI approach with STEMI/non-STEMI paradigm. This is the largest study specifically designed to challenge 20 years of unquestioned dominance of the STEMI/non-STEMI paradigm. Over one-fourth of the patients initially classified as having non-STEMI were re-classified by the ECG reviewers as having OMI. Furthermore, early intervention in patients with OMI-predicting ECGs was associated with lower long-term mortality. The left-handed side is designed to exclude OMI mimics, and the right-handed side is designed to uncover OMIs that are not fulfilling STEMI criteria. 
[LBBB, left bundle branch block; LVH, left ventricular hypertrophy; MI, myocardial infarction; OMI, occlusion myocardial infarction; STD, ST-segment depression; STE, ST-segment elevation]
Aslanger EK, et al. DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT study). Int J Cardiol Heart Vasc. 2020; 30: 100603.
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Occlusive Myocardial Infarction?

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Occlusive Myocardial Infarction (OMI)?

Aslanger OMI Pattern

  • New ECG pattern that is not uncommon among patients classified as non-STEMI (6.3%).

  • 13.3% of inferior MIs presents with this pattern and may be deprived of primary PCI because of the incorrect label of non-STEMI.

  • It indicates an acute atherothrombosis event that frequently due to inferior MI despite ECG not showing contiguous STE.

  • The patients with this pattern have higher short- and long-term risk for mortality.

  • Since there is more than one critical lesion, it may cause confusion about which lesion should be emergently opened.

  • Usually related to the vessel supplying the inferior wall (RCA vs. Cx artery

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Recognize the importance of diagnosing Right Ventricular infarction in a patient with inferior STEMI.
This occurs in up-to 50% of the cases. 
Usually asociated to higher STE in lead III, compared to lead II and aVF. May be accompanied with V1 STE. Should be confirmed with a right sided ECG (RV4-RV6).

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RV infarction is associated with high in-hospital morbidity and mortality. Ischemic right ventricular (RV) systolic dysfunction decreases left ventricular preload delivery, resulting in low-output hypotension with clear lungs, and disproportionate right heart failure. Usually may be associated with vagal mediated bradyarrhythmias, CAVB and malignant ventricular arrhythmias.

JACC FOCUS SEMINAR
Right Ventricular Myocardial Infarction—A Tale of Two Ventricles (J Am Coll Cardiol 2024)

American College of Cardiology (ACC) /
American Heart Association (AHA) Guidelines

  • Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction, Focused Update: An Update of the Guideline for Percutaneous Coronary Intervention and the Guideline for the Management of ST-Elevation Myocardial Infarction (Published: Oct 21, 2015)

  • 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction (Published: Dec 17, 2012)

  • 2021 ACC/AHA/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain

  • ESC 2020 Acute Coronary Syndromes (ACS) in Patients Presenting without Persistent ST-Segment Elevation (Management of NSTE-ACS) Guidelines

  • 2014 ACC/AHA Non-ST-Elevation Acute Coronary Syndromes, Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (Published: Sep 23, 2014)

  • Fourth Universal Definition of Myocardial Infarction. Expert Consensus 2018.(Published in the European Heart Journal: Aug / 2018).

  • Closing Gaps in Essential Chest Pain Care Through Accreditation. Winchester D, Osborne A, Peacock F, Bhatt D, Dehmer G, et al. JACC 2020 (May); Volume 75 (19): 2478-82.

  • ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. (Published: Nov 12, 2012)

2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 

  • Part 1: Executive Summary: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

  • Part 5: Acute Coronary Syndromes: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Published: 2015)

Emergency Medical Services (EMS) and Prehospital Management of STEMI 

  • The Impact of a Statewide Pre-Hospital STEMI Strategy to Bypass Hospitals Without Percutaneous Coronary Intervention Capability on Treatment Times. (Published: December 30, 2012)

  • Emergency medical services management of STEMI in the United States—a report from the American Heart Association Mission: Lifeline Program (Published: April 2014) 

Mission: Lifeline Program Against STEMI (from the American Heart Association)

  • Regional Systems of Care Demonstration Project AHA Mission: Lifeline STEMI Systems; Accelerator (Circ.2016)

  • About Mission: Lifeline (AHA site link)

  • Mission: Lifeline Tools and Resources for EMS (AHA site link)

  • Mission: Reperfussion Check List (AHA Site Resource)

  • Heart Attack Patient Education Portal (AHA site link)

  • Heart Attack Video (Just a Little Heart Attack; From AHA Go RED for Women)

ACS Related Website Links & Articles 

  • Society of Cardiovascular Patient Care (SCPC); with Available Resources

  • ECG Training Resource by Wayne Ruppert; on-site comprehensive ECG and other cardiology related trainings (including ACS, cardiac arrhythmias, SCD and ACLS) for medical professionals.

  • Article: A Young Female With a Broken Heart

  • Multichannel Electrocardiograms Obtained by a Smartwatch for the Diagnosis of ST-Segment Changes. JAMA Cardiol. Published online August 31, 2020.

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Prompt performance of an electrocardiogram (ECG) in patients presenting to the emergency department (ED) with acute myocardial infarction (AMI) leads to early diagnosis and treatment.
The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend that, when a patient reporting chest pain or equivalent AMI symptoms arrives in the ED, an ECG should be obtained and read within 10 minutes.

Escabí J, Oviedo R. Early ECG Performance in Patients Presenting with Acute Myocardial Infarction to Emergency Department at the San Juan Veterans Hospital. Federal Practitioner 2010, April; Vol. 27, No. 4: 41-49.

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