Impact of guidelines-directed very-high-risk criteria in the identification and management of occlusion myocardial infarction in patients with NSTE-ACS.

AIMS: Guidelines recommend immediate invasive management for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients meeting very high-risk (VHR) criteria. Whether these criteria identify occlusion myocardial infarction (OMI) and expedite reperfusion is uncertain. METHODS AND RESULTS: This post-hoc analysis included 2979 NSTE-ACS patients undergoing percutaneous coronary intervention (PCI) in the MATRIX programme with available culprit-lesion flow. OMI was defined as culprit-vessel TIMI flow 0-1. We evaluated European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) VHR criteria for OMI detection and time from first medical contact (FMC) to PCI. OMI occurred in 592 patients (19.9%). At least one VHR criterion was present in 52.9% according to ESC and 14.1% according to ACC/AHA definitions. Among patients with OMI, only 58.1% fulfilled ESC and 24.1% ACC/AHA criteria. Median FMC-to-PCI time was shorter in patients fulfilling ESC criteria (27.0 vs. 40.5 h) or ACC/AHA VHR criteria (12.2 vs. 69.9 h; both P < 0.001). Nevertheless, PCI within 2 h occurred in only 2.6% and 7.7% of patients meeting ESC and ACC/AHA criteria, respectively, and in 3.6% of patients with OMI. Even among OMI patients fulfilling VHR criteria, timely reperfusion within 2 h occurred only 4.7% and 9.9%. CONCLUSION: Guideline-directed VHR criteria had limited sensitivity for OMI and rarely translated into guideline-recommended immediate PCI. Current NSTE-ACS classification and triage strategies require reconsideration to improve recognition and timely reperfusion of acute coronary occlusion.