闭塞聚焦分诊 vs 极高危NSTEMI标准：DIFOCCULT-3子研究。
完整摘要 · 中文译文
背景：目前的ST段抬高型心肌梗死（STEMI）/非ST段抬高型心肌梗死（NSTEMI）框架可能无法完全识别出无诊断性STE的急性冠脉闭塞（ACO）患者。尽管指南推荐对具有极高危NSTEMI特征的患者进行立即有创管理，但这些标准在临床实践中的应用并不一致。OMI/NOMI框架已被提议作为替代策略。 目的：本研究旨在比较闭塞性/非闭塞性心肌梗死（OMI/NOMI）分类与指南定义的极高危非ST段抬高型心肌梗死（NSTEMI）标准，在无诊断性STE患者中识别急性冠脉闭塞（ACO）的能力。 方法：本研究是多中心、整群随机DIFOCCULT-3（从ST段抬高/非ST段抬高向闭塞/非闭塞心肌梗死的诊断范式转变-3）试验的一项子研究。连续纳入入院心电图上无诊断性STE的成年患者，并按照常规STEMI/NSTEMI或OMI/NOMI方法进行管理。极高危NSTEMI根据现行指南定义。结局包括立即有创管理（2小时内）和裁定的ACO。 结果：在4,398例患者中，极高危NSTEMI标准识别出的患者比例较小，且不一致地转化为早期干预。与STEMI/NSTEMI框架相比，OMI/NOMI方法选择了更多患者接受早期有创管理（45.4% vs 13.6%；P < 0.001）。裁定的ACO w 在OMI/NOMI方法下，2小时内被识别出的情况更频繁（35.1%对16.7%；P < 0.001），且血管造影检出率未见降低。 结论：以闭塞为焦点的诊断方法与即时有创管理率的显著提高以及经判定ACO患者的更早识别相关。
完整摘要 · 英文原文
BACKGROUND: The current ST-segment elevation myocardial infarction (STEMI)/NSTEMI framework may not fully identify patients with ACO who present without diagnostic STE. Although immediate invasive management is recommended for patients with very-high-risk NSTEMI features, these criteria are inconsistently applied in clinical practice. The OMI/NOMI framework has been proposed as an alternative strategy. OBJECTIVES: This study sought to compare the occlusive and nonocclusive myocardial infarction (OMI/NOMI) classification with guideline-defined very-high-risk non-ST-segment elevation myocardial infarction (NSTEMI) criteria for the identification of acute coronary occlusion (ACO) in patients without diagnostic STE. METHODS: This was a substudy of the multicenter, cluster-randomized DIFOCCULT-3 (Time for a Diagnostic Paradigm Shift From ST-Elevation/Non-ST-Elevation to Occlusion/Non-Occlusion Myocardial Infarction-3) trial. Consecutive adult patients without diagnostic STE on the admission electrocardiogram were included and managed according to either the conventional STEMI/NSTEMI or the OMI/NOMI approach. Very-high-risk NSTEMI was defined according to current guidelines. Outcomes included immediate invasive management (within 2 hours) and adjudicated ACO. RESULTS: Among 4,398 patients, very-high-risk NSTEMI criteria identified a small proportion of patients and were inconsistently translated into early intervention. The OMI/NOMI approach selected more patients for early invasive management compared with the STEMI/NSTEMI framework (45.4% vs 13.6%; P < 0.001). Adjudicated ACO was identified within 2 hours more frequently under the OMI/NOMI approach (35.1% vs 16.7%; P < 0.001), without reduction in angiographic yield. CONCLUSIONS: An occlusion-focused diagnostic approach was associated with substantially higher rates of immediate invasive management and earlier identification of patients with adjudicated ACO.