European Heart Journal Advance Access originally published online on May 24, 2007
European Heart Journal 2007 28(12):1403-1404; doi:10.1093/eurheartj/ehm159
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STEMI and NSTEMI: the dangerous brothers
Department of Cardiology and Angiology, III. Medizinische Universitaetsklinik, Hugstetter Str. 55, 79106 Freiburg, Germany
* Corresponding author. Tel: +49 761 270 3441; fax: +49 761 270 3200. E-mail address: christoph.bode{at}uniklinik-freiburg.de
This editorial refers to ‘STEMI and NSTEMI: are they so different? 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry)’ by G. Montalescot et al., on page 1409
Ever since the redefinition of myocardial infarction (MI) in the year 2000,1 a new entity has entered the field: non-ST-elevation MI (NSTEMI). STEMI and NSTEMI share the release of specific myocardial necrosis markers which define them clinically as acute MI (AMI) and set them apart from unstable angina, an acute coronary syndrome which does not qualify as MI.
NSTEMI: getting to know the younger brother
With the creation of the NSTEMI as a new clinical entity, the need for data regarding prognosis and treatment options arose. By definition, STEMI and NSTEMI are only different with respect to the reflection of acute myocardial ischaemia and necrosis in the ECG. Although this difference may be triggered by the size of the infarcted area, it may also be only the location of the infarct—an occluded circumflex artery does not project equally well on the ECG as does an occluded right coronary artery. Furthermore, specificity and sensitivity of ECG changes are influenced by several other factors including prior MI, bypass surgery, variation of coronary anatomy, bundle-branch block, and others. Are these differences meaningful—should they lead to different clinical approaches—as the guidelines currently recommend?
Are treatment strategies that have been tested before the redefinition of AMI, such as thrombolytic therapy, and that have shown to be beneficial in STEMI and non-beneficial in other acute coronary syndromes applicable to NSTEMI patients? Certainly not without further research.
Montalescot et al.2 are to be congratulated for extending our knowledge about the relative prognosis and treatment reality of STEMI and NSTEMI significantly. OPERA is a multicentre, countrywide registry in France that compared outcome and treatment of 2151 patients from 56 centres at hospital discharge and at 1 year. The results show that patients with NSTEMI and STEMI have comparable in-hospital and long-term prognosis. They also have similar independent correlates of adverse outcome. However, NSTEMI patients undergo less and later reperfusion and also less consequent secondary prevention.
The majority of previous registries have shown similar results, OPERA being of special interest because it was performed in a country with aggressive reperfusion policy and widely available cath-lab facilities.
A pattern emerging from registries is that STEMI patients are younger and have more myocardium at stake and less cardiac and non-cardiac concomitant diseases. NSTEMI patients are older and have had more prior cardiac damage and also non-cardiac disease. Even though their acute cardiac damage is less, NSTEMI can be considered as a ‘last straw’ that pulls an already overburdened heart down.
Progress in the treatment of MI has been rapid in the past years; however, most studies focused on STEMI. Most recently, individual trials and meta-analyses3 have been published that address NSTEMI as a unique entity. In fact, there are now numerous studies underway that will define the short- and long-term benefits of various antithrombotic approaches as well as those of an early invasive vs. conservative strategy.
As a clinical consequence, we would go along with the conclusions that Montalescot et al.2 offer: NSTEMI patients appear to be undertreated with respect to reperfusion and also after discharge from hospital. The similar prognosis of NSTEMI and STEMI patients should lead to a more aggressive in-hospital and secondary prevention treatment of both groups, particularly the NSTEMI population. A primary research goal should be to find out which individuals derive most benefit from such a more aggressive approach. Even after ISAR-COOL and ICTUS, this remains somewhat controversial.4,5 However, all of these strategies derived from well-designed registries still need to be confirmed in large, randomized, clinical outcome studies. Until proven otherwise, STEMI and NSTEMI are no identical twins, but equally dangerous.
Conflict of interest: none declared.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
doi:10.1093/eurheartj/ehm031 References
- Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined—a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol (2000) 36:959–969.
[Free Full Text] - Montalescot G, Dallongeville J, Van Belle E, Rouanet S, Baulac C, Degrandsart A, Vicaut E. STEMI and NSTEMI: are they so different? 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry). Eur Heart J (2007) 28:1409–1417.
[Abstract/Free Full Text] - Hoenig MR, Doust JA, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST-elevation myocardial infarction in the stent era. Cochrane Database Syst Rev (2006) 3:CD004815.[Medline]
- Neumann FJ, Kastrati A, Pogatsa-Murray G, Mehilli J, Bollwein H, Bestehorn HP, Schmitt C, Seyfarth M, Dirschinger J, Schömig A. Evaluation of prolonged antithrombotic pretreatment (‘cooling-off’ strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA (2003) 290:1593–1599.
[Abstract/Free Full Text] - Hirsch A, Windhausen F, Tijssen JG, Verhengt FW, Cornel JH, de Winter RJ. Long-term outcome after an early invasive versus selective treatment strategy in patients with n-ST-elevation acute coronary syndrome and elevated cardiac troponin T (the ICTUS trial): a follow-up study. Lancet (2007) 369:827–835.[CrossRef][ISI][Medline]
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Related articles in EHJ:
- STEMI and NSTEMI: are they so different? 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry)
- Gilles Montalescot, Jean Dallongeville, Eric Van Belle, Stephanie Rouanet, Cathrine Baulac, Alexia Degrandsart, Eric Vicaut, and for the OPERA Investigators
EHJ 2007 28: 1409-1417.[Abstract] [Full Text]
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