Background: Patients may present with acute coronary occlusions (ACO) without manifesting electrocardiographic STEMI criteria.
Objective: Examine incidence, clinical characteristics, and in-hospital outcomes of NSTEMI with ACO.
Methods: We included patients with STEMI and NSTEMI in the CathPCI Registry who underwent percutaneous coronary intervention between 4/1/2018-6/30/2023. 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 0-1 culprit artery flow was performed.
Results: Of 1,198,544 patients, 26.1% had STEMI, 11.0% had NSTEMI-ACO (15% of NSTEMI), and 62.9% had NSTEMI-no-ACO. Compared 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). NSTEMI-ACO had a higher risk of the primary composite compared with NSTEMI-no-ACO (Adjusted OR 2.26 [2.18-2.34]; p < 0.001), but a lower risk compared to STEMI (Adjusted OR 0.54 [0.52-0.56], p < 0.001). Using a definition of ACO including TIMI 0-1 flow, NSTEMI-ACO accounted for 216,054 presentations (24.4% of 2 46 NSTEMI). In-hospital outcomes were similarly worse compared with NSTEMI-no-ACO and 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 better compared with STEMI.
Conclusions: ACO occurs in a substantial proportion of NSTEMI and is associated with worse in-hospital outcomes relative to NSTEMI-no-ACO. Further studies of early identification and reperfusion practices for NSTEMI-ACO are warranted.
Editors
Editor-in-Chief
Harlan M. Krumholz, MD, SM, FACC
CME Editor
Ragavendra R. Baliga, MD
Author
Riyad Kherallah, MD
Important Dates
Date of Release: September October 12, 2026
Term of Approval/Date of CME/MOC Expiration: October 11, 2027