Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (PMcardio, queen of hearts)

Published in: The American Journal of Emergency Medicine
Published on: 30 July 2025

Background

Accurate ECG interpretation is crucial to identify occlusive myocardial infarction (OMI) to determine the need for immediate catheterization laboratory activation (CLA). STEMI-equivalent and STEMI-mimic ECG patterns deviate from conventional STEMI criteria, risking misclassification of OMI cases. The diagnostic accuracy for these complex ECGs is unknown.

Methods

Fifty-three EPs and 42 cardiologists interpreted 18 ECGs (eight STEMI-equivalents, eight STEMI-mimics, with one STEMI, and a normal ECG as controls) to determine the presence of OMI requiring immediate CLA. The same ECGs were analyzed by QoH AI. Interpretations were compared against a reference standard based on angiography, troponin, echocardiography, and clinical follow-up.

Results

Interpretation accuracies were similar between EPs and cardiologists (65.6 %, 95 % CI [51, 78]; 65.5 %, 95 % CI [51, 77], respectively; p = 0.969), and significantly lower than QoH AI (88.9 %, 95 % CI [82, 93]) vs. physicians overall, 65.6 %, 95 % CI [52, 77]; p < 0.001). Physicians most frequently misclassified de Winter, Transient STEMI, Hyperacute T-wave OMI, and bundle branch block ECGs. QoH AI only misclassified left bundle branch block with OMI and left ventricular aneurysm without OMI.

Conclusion

Physicians frequently misinterpret STEMI-equivalent and STEMI-mimic ECGs, potentially impacting CLA decisions. QoH AI demonstrated superior accuracy, suggesting a potential to reduce missed OMIs and unnecessary catheterization laboratory activations. Prospective studies are needed to validate these findings in clinical practice.