ST-Segment Elevation vs. Non-ST-Segment Elevation Acute Coronary Syndromes: Clinical, Metabolic and Angiographic Divergences in a Real-World Setting

Abstract

Background: Recent guidelines emphasize the pathophysiological continuum of acute coronary syndromes (ACS). However, the real-world clinical presentation of ST-segment elevation myocardial infarction (STEMI) compared to non-ST-segment elevation myocardial infarction (NSTEMI) differs considerably. Aim: The objective of this study is to compare the clinical characteristics, metabolic profiles, and angiographic severity between patients admitted for STEMI and those admitted for NSTEMI. Methods: This was a single-center, observational, and analytical study conducted over a 6-month period at the Cardiology Department of the Mohammed VI University Hospital (CHU Mohammed VI) in Marrakesh, Morocco. Following written informed consent, it included 144 consecutive adult patients admitted for ACS who underwent diagnostic coronary angiography, strictly excluding those managed with an exclusively conservative strategy. Clinical data, metabolic profiles, and angiographic findings were systematically extracted and compared. Results: The study included 97 STEMI patients (67.4%) and 47 NSTEMI patients (32.6%). The overall mean age was 63.7 ± 10.1 years. The NSTEMI group had a significantly higher proportion of females (55.3% vs. 26.8% in the STEMI group, p = 0.002) and hypertensive patients (61.7% vs. 27.8%, p < 0.001). Active smoking was predominant in the STEMI group (49.5% vs. 25.5%, p = 0.011). The metabolic burden was substantial and similar across both groups, particularly for diabetes (53.2% NSTEMI vs. 51.5% STEMI) and dyslipidemia (44.7% NSTEMI vs. 47.4% STEMI). Angiographically, STEMI was predominantly associated with single-vessel disease (56.7%) involving the left anterior descending artery (LAD, 63.9%). Conversely, NSTEMI involved the left circumflex artery (LCx) significantly more often (23.4% vs. 10.3%, p = 0.001) and was more frequently associated with severe triple-vessel disease (21.3% vs. 10.3%, p = 0.179). Conclusion: This study confirms a profound dimorphism in the real-world presentation of ACS that often diverges from classic guideline paradigms. While STEMI predominantly characterizes younger, smoking males with single-vessel LAD occlusion, NSTEMI frequently involves older, hypertensive females presenting with complex, diffuse, and sometimes angiographically occlusive multivessel disease. Recognizing these real-world discrepancies is crucial for avoiding treatment delays and optimising individualised management.