Coronary intervention in non-ST elevation infarction - is the delay the right way?

Acute myocardial infarction (AMI) is necrosis due to hypoperfusion-induced hypoxia of myocardial cells. In most of pts. causes chest pain and/or dyspnoea, ECG changes (elevation or depression of ST segment, in some cases associated with rhythm and/or conduction disorders). These form the basis for the primary diagnosis. AMI is caused of severe coronary artery stenosis or occlusion in the majority of patients, but it can also occur by coronarography invisible artery wall lesions (MINOCA). If the hypoperfusion is caused by severe stenosis or occlusion of the main epicardial coronary arteries, the cell necrosis can be reduced to improve perfusion using catheter-based or surgical methods. The extent of hypoxic myocardial damage is time-dependent; to clean the diagnosis, and the way of treatment requires a quick decision. The non-ST elevation form (NSTEMI) is mostly associated with less complaints than the ST elevation form (STEMI), the ECG abnormalities are sometimes atypical, it is often difficult to diagnose from the clinical symptoms at an early stage, even though left main stem stenosis (LMS) could be the main cause. In our Dept between 4208 acute myocardial infarction cases (2023 STEMI and 2125 NSTEMI) underwent event-level PCI from 01/01/2021 to 12/12/2024, STEMI 71,6 %, and NSTEMI 36,7% were admitted primarily. The time between the onset of complaints and the first ECG investigation was 5: 51 in STEMI vs. 12:42 hours in NSTEMI, as well as to the balloon opening 7:26 vs. 22:43 hour between complaint onset and coronary balloon inflation. The ratio of patients for initial medical evaluation in the first 4 hours was less, later than 12 hours was more in NSTEMI compared to the STEMI cases. Besides of medical treatment (digitalis/SGLT-2 inhibitor, diuretics), mechanical support for breathing (IPPB) was needed in 5,4%, for circulation (IABP/ECMO) in 0.5% of the patients in NSTEMI interventions. The STEMI vs. NSTEMI one-year mortality rate was 16,3% vs. 14,2%, the difference was higher at 30 days, 10,2% vs. 6,3%. As we have learned in the last 30 years in management of STEMI, apart from coronary angiography is no other rapid method to determine where the infarction falls on the broad spectrum ranging from three-vessel disease with LMS, to MINOCA. The level of troponin-T indicates the size, and echocardiography the size and localization of the infarction, but helps not in the basic cause and the followings, only the above-mentioned data helps together in choosing between pharmacological, coronary interventional (PCI) or surgical (CABG) treatment. Based on the prior knowledges of other investigators, and our mortality data, the non-ST-elevation myocardial infarction is not considered less harmful than the ST-elevation type. The exact anatomical knowledge of coronary vessels, and the possibility of subsequent invasive therapy if needed, would be advisable to send the patients with NSTEMI to an intervention center earlier than at the present practice.