JACC Cardiovasc Interv. 2026 Oct 12;19(19):2539-2551. doi: 10.1016/j.jcin.2026.07.032.
ABSTRACT
BACKGROUND: Patients may present with acute coronary occlusions (ACOs) without manifesting electrocardiographic criteria for ST-segment elevation myocardial infarction (STEMI).
OBJECTIVES: The aim of this study was to examine the incidence, clinical characteristics, and in-hospital outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) with ACO.
METHODS: The study included patients with STEMI and NSTEMI in the CathPCI Registry who underwent percutaneous coronary intervention between April 1, 2018, and June 30, 2023. ACO was defined as 100% stenosis deemed acute. The cohort was stratified into STEMI (including STEMI equivalents), NSTEMI-ACO, and NSTEMI-no-ACO. The primary outcome was a composite of in-hospital stroke, myocardial infarction, or cardiovascular mortality. A sensitivity analysis with ACO defined as 100% acute occlusion or TIMI flow grade 0 or 1 in the culprit artery was performed.
RESULTS: Of 1,198,544 patients, 26.1% had STEMI, 11.0% had NSTEMI-ACO (15% of whom had NSTEMI), and 62.9% had NSTEMI-no-ACO. Compared with those with NSTEMI-no-ACO, NSTEMI-ACO patients had more cardiogenic shock (9.0% STEMI vs 3.8% NSTEMI-ACO vs 1.9% NSTEMI-no-ACO; P < 0.001), ventricular arrhythmias (4.9% vs 2.0% vs 1.3%; P < 0.001), and in-hospital cardiac arrest (6.1% vs 2.7% vs 1.6%; P < 0.001). Patients with NSTEMI-ACO had a higher risk for the primary composite compared with those with NSTEMI-no-ACO (adjusted OR: 2.26; 95% CI: 2.18-2.34; P < 0.001) but a lower risk compared with those with STEMI (adjusted OR: 0.54; 95% CI: 0.52-0.56; P < 0.001). Using a definition of ACO including TIMI flow grade 0 or 1, NSTEMI-ACO accounted for 216,054 presentations (24.4% of NSTEMI). In-hospital outcomes were similarly worse compared with NSTEMI-no-ACO and better compared with STEMI.
CONCLUSIONS: ACO occurs in a substantial proportion of patients with NSTEMI and is associated with worse in-hospital outcomes relative to those with NSTEMI-no-ACO. Further studies of early identification and reperfusion practices for NSTEMI-ACO are warranted.
PMID:42863865 | DOI:10.1016/j.jcin.2026.07.032