The OMI Manifesto: A Call for Change in Acute MI Management

Introduction

• The current acute MI management paradigm (STEMI vs. NSTEMI) is flawed and impedes progress in reperfusion therapy.
• Dr. Stephen Smith and colleagues argue that the STEMI term restricts the diagnosis of Acute Coronary Occlusion (ACO).
• Current STEMI criteria miss 25-30% of ACO cases and produce false positives, prompting the need for a new paradigm.

Historical Background

• The STEMI-NSTEMI paradigm, introduced in 2000, replaced Q-wave vs. Non-Q-wave MI to reflect the Reperfusion Era’s advances.
• Early trials showed thrombolytics had a mortality benefit, though ECG criteria were not well-defined then.
• Advances in ECG interpretation since the 1994 FTT meta-analysis show that STE is not the best predictor of ACO.

Issues with Current Criteria

• ACO is dynamic and may not always show STE; early stages often lack STE.
• Current criteria do not account for variations in ST segment changes due to different conditions or ECG recordings.
• Many conditions mimic ECG findings suggestive of ACO.

Proposed Changes: OMI vs. NOMI

• Proposes the term Occlusion Myocardial Infarction (OMI) to replace STEMI.
• Emphasizes identifying ACO rather than relying solely on STE.
• Identifying OMI focuses on actual benefit from emergent reperfusion therapy, regardless of ECG findings.

Part I: History of STEMI and Reperfusion

• The Reperfusion Era demonstrated the success of reperfusion therapy without clear ECG criteria.
• Guidelines have relied on STE despite its limitations in identifying ACO.

Part II: Failures of STEMI Criteria

Key Points:

1. High Miss Rate: 25-30% of NSTEMI cases are actually ACOs.
2. Physician Interpretation Issues: Poor accuracy and agreement in diagnosing ACO.
3. Measurement Discrepancy: Variability in ST segment interpretation.
4. Cognitive Bias: The term "STEMI" misleads focus to only ST segments.

Studies Highlighting Failures:

• Multiple studies showed significant proportions of ACO cases missed under current STEMI criteria.
• Diagnostic tools and criteria fail to adequately identify patients who would benefit from emergent intervention.

Part III: Towards a New Paradigm

• Advocate for retiring the term "STEMI" for "OMI" and "NOMI."
• OMI emphasizes acute thrombotic occlusion for immediate intervention.
• Suggests a shift in focus away from solely ECG criteria to a broader assessment of ACO.

Conclusion

• The OMI Manifesto calls for a paradigm shift in acute MI management.
• Encourages clinicians to adopt OMI/NOMI terminology to improve patient outcomes.
• Highlights the importance of continuous learning and adaptation in medical practice.

Resources for Further Learning

• Dr. Smith’s ECG Blog
• EMCrit Podcasts: Who Needs an Acute PCI with Steve Smith

References

• List of key studies and meta-analyses supporting the manifesto’s propositions.