Acute Coronary Syndrome; an Evolution to our Approach (OMI/NOMI)

Our current paradigm (STEMI/NSTEMI) is failing us and our patients.

This is a broad overview and discussion on why the current STEMI/NSTEMI paradigm is no longer fit for purpose. Although ST elevation is a vitally important ECG change to recognise, over-emphasis on this morphology risks missing many acute coronary occlusions, as we will see here.

This is a non-technical talk, focusing on a change in mindset and framing for ACS recognition. I’ll aim to create a future video going through some specific ECG findings to recognise for occlusion myocardial infarction.

In the meantime, the videos and resources below will do a better job than I ever could:

Recommended videos (and references/credit to these for a lot of my material):

  1. Stephen Smith; Myocardial Infarction;
  2. OMI Manifesto Lecture;…
  3. Pendell Meyers; The OMI Manifesto;
  4. ST-Segment and T-Wave Ischemia | The Advanced EM Boot Camp ECG Workshop;
  5. Amal Mattu; BER vs STEMI;

Links and references below for more:

  1. Meyers P, Weingart S, Smith S. The OMI Manifesto. Dr Smiths ECG Blog; EmCrit. 2018;…
  2. LITFL; Replacing the STEMI Minsomer;…
  3. S Smith, Weingart S. Who Needs the Cath Lab / Cards Consult ? EmCrit. 2018;
  4. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Lancet. 1994 Feb 5;343(8893):311-22. Erratum in: Lancet 1994 Mar 19;343(8899):742.PMID: 7905143.
  5. Lee ZV, Hanif B. Historical Perspectives on Management of Acute Myocardial Infarction. In: Primary Angioplasty. 2018.
  6. Aslanger EK, Meyers PH, Smith SW. Time for a new paradigm shift in myocardial infarction. Anatol J Cardiol. 2021;
  7. Abdur R. Khan, Harsh Golwala, Avnish Tripathi, Aref A. Bin Abdulhak, Chirag Bavishi, Haris Riaz, Vishnu Mallipedi, Ambarish Pandey, Deepak L. Bhatt, Impact of total occlusion of culprit artery in acute non-ST elevation myocardial infarction: a systematic review and meta-analysis, European Heart Journal, Volume 38, Issue 41, 01 November 2017, Pages 3082–3089,
  8. Aslanger EK, Yıldırımtürk Ö, Şimşek B, et al. DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study). Int J Cardiol Heart Vasc. 2020;30:100603. Published 2020 Jul 30. doi:10.1016/j.ijcha.2020.100603