Reviews
Vol. 21 No. 4 (2025)
Missed occlusions: diagnostic accuracy of ECG STEMI criteria for identifying occlusive myocardial infarction. A systematic review and meta-analysis
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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Published: 2 December 2025
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The ECG-STEMI criteria are widely used to identify Acute Myocardial Infarction (AMI) patients who need urgent revascularization. However, recent evidence shows that up to one-third of Occlusive Myocardial Infarctions (OMIs) may go undetected using these criteria. While still a cornerstone of current triage protocols, doubts remain about their diagnostic accuracy, particularly their sensitivity in detecting OMI. This systematic review and meta-analysis aimed to assess the diagnostic accuracy of ECG-STEMI criteria in identifying patients with OMI. A comprehensive search of MEDLINE, EMBASE, and Scopus was conducted up to February 2024. Included studies enrolled patients with confirmed AMI and provided data to construct 2×2 tables comparing ECG-STEMI results (index test) with angiographic findings (reference standard) for OMI. Risk of bias was assessed using QUADAS-2. We calculated pooled sensitivity, specificity, diagnostic odds ratio (DOR), and generated SROC curves using random-effects models. Nine studies (11,757 patients) were included. ECG-STEMI criteria showed a pooled sensitivity of 0.635 (95% CI: 0.549–0.713) and specificity of 0.780 (95% CI: 0.645–0.873). The DOR was 5.94 (95% CI: 3.81–9.27), with an AUC of 0.752 (95% CI: 0.714–0.795). Definitions of OMI varied across studies; composite definitions yielded higher specificity and DOR but lower sensitivity than angiographic definitions alone. ECG-STEMI criteria offer high specificity but only moderate sensitivity for detecting OMI, potentially missing one-third of patients needing urgent care. These criteria are more reliable for confirming rather than excluding OMI. Diagnostic accuracy depends on how OMI is defined, highlighting the need for a standardized definition to better assess both current and emerging ECG criteria.
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How to Cite
Missed occlusions: diagnostic accuracy of ECG STEMI criteria for identifying occlusive myocardial infarction. A systematic review and meta-analysis. (2025). Emergency Care Journal, 21(4). https://doi.org/10.4081/ecj.2025.14233
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