Occlusion-Focused Triage vs Very-High-Risk NSTEMI Criteria: A DIFOCCULT-3 Substudy
In brief
Occlusion-focused triage identified twice as many coronary blockages within 2 hours
In a substudy of 4,398 patients without diagnostic ST elevation, the occlusion-focused approach led to immediate invasive management in 45% of patients, versus 14% with the conventional approach. Acute coronary occlusion was identified within 2 hours in 35% versus 17%, without reducing angiographic yield; whether this earlier identification improves patient outcomes remains unknown.
- Journal
- JACC. Cardiovascular interventions (Q1)
- Published
- 12 October 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Emre K Aslanger, Burcu Aggül, Özlem Yıldırımtürk, Can Yücel Karabay, Harvey Pendell Meyers, Stephen W Smith, et al.
- PMID
- 42863867
- DOI
- 10.1016/j.jcin.2026.06.040
Why clinicians should know about it
- Picked for Emergency Medicine (paper of the day, 14 October 2026): Occlusion-focused triage, higher early invasive management vs NSTEMI criteria
Abstract
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.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.