You are here

Article Text

Article menu
Download PDFPDF
Opinion
No false negative paradox in STEMI-NSTEMI diagnosis
  1. José Nunes de Alencar1,
  2. H Pendell Meyers2,
  3. Jesse T T McLaren3,4,
  4. Stephen W Smith5,6
  1. 1Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
  2. 2Carolinas Medical Center, Charlotte, North Carolina, USA
  3. 3Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  4. 4Emergency Department, University Health Network, Toronto, Ontario, Canada
  5. 5Emergency Department, Hennepin County Medical Center, Minneapolis, Minnesota, USA
  6. 6Emergency Medicine, University of Minnesota System, Minneapolis, Minnesota, USA
  1. Correspondence to Dr José Nunes de Alencar, Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil; jose.alencar{at}dantepazzanese.org.br

https://doi.org/10.1136/heartjnl-2024-324512

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Introduction

    ST-segment elevation myocardial infarction (STEMI) diagnosis is based on a clinical presentation and ST-segment elevation (STE) in at least two consecutive leads. Despite being deeply rooted in both the literature and in current medical knowledge and having been pivotal in advancing reperfusion therapy for patients with acute myocardial infarction (MI), the diagnosis of STEMI presents a significant issue: What we, the authors, call the ‘no false negative paradox’. This paradox potentially makes it challenging to recognise a false negative diagnosis of STEMI and makes it difficult to appreciate the significance of an acute coronary occlusion (ACO) that could benefit from early reperfusion in door-to-needle or door-to-balloon times despite the absence of STE.1

    This paradox stems from the incorporation bias and feedback sanction bias detailed in subsequent paragraphs. This is an opinion paper where the patient and the public were not involved.

    The incorporation bias

    In conducting diagnostic test accuracy studies, the selection of the population, index test and reference test prior to study execution is fundamental. However, a methodological problem arises when the index test and the reference test are identical or when they overlap which is known as ‘incorporation bias’.2 This bias falsely inflates the accuracy of the results of the study above their true value. During ACO, for someone to be considered ‘diseased’ (STEMI), the presence of parts of the definition of ‘diseased’ (STE) is mandatory. This makes ‘diseased’ and ‘positive’ almost the same causing sensitivity (the ability of a test to detect true positives among the diseased) to appear as 100% because the test is essentially comparing itself to a mirror. The problem is that a perfectly sensitive test has no false negatives. Because STE is part of both the test and the disease definition, the absence of …

    View Full Text

    Footnotes

    • X @josenalencar, @smithECGBlog

    • Contributors JNdA, HPM, JTTM and SWS were involved in the study design, data acquisition and interpretation of results. All authors contributed equally to the planning, conduct and reporting of the work described in the article. They were also involved in drafting and critically reviewing the manuscript. All authors approved the final version. JNdA, HPM, JTTM and SWS share the responsibility as guarantors of this manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.