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Background: Non–ST elevation myocardial infarction (NSTEMI) represents a heterogeneous clinical entity. A subset of NSTEMI patients harbor total or near total coronary artery occlusion, often resembling STEMI equivalents, yet may not receive immediate invasive management. Early identification of high-risk angiographic patterns is crucial for optimizing outcomes. Objective: To identify clinical, biochemical, electrocardiographic, and risk profile factors associated with total and near total coronary artery occlusion among NSTEMI patients. Methods: A cross-sectional study was conducted in the Department of Cardiothoracic and Vascular Surgery at AIMST University, Malaysia. A total of 200 consecutive NSTEMI patients undergoing coronary angiography were included. Demographic variables, cardiovascular risk factors, clinical presentation, ECG findings, troponin levels, echocardiographic parameters, and TIMI and HEART scores were recorded. Coronary angiography findings were classified as total/near total occlusion (≥90% stenosis) or non-critical lesions. Statistical analysis was performed using SPSS. Associations were assessed using Chi-square and independent t-tests. Multivariate logistic regression identified independent predictors of total occlusion. A p-value <0.05 was considered statistically significant. Results: Total or near total occlusion was observed in 78 patients (39%). Patients with occlusion had significantly higher troponin levels (p <0.001), higher TIMI scores (p = 0.002), and more frequent anterior wall ischemic changes on ECG (p = 0.004). Diabetes mellitus (p = 0.01), smoking (p = 0.003), and delayed presentation (p = 0.02) were significantly associated with occlusion. On multivariate analysis, elevated troponin (AOR 3.6; p <0.001), smoking (AOR 2.8; p = 0.004), high TIMI score (AOR 2.5; p = 0.01), and anterior ECG changes (AOR 3.1; p = 0.002) independently predicted total occlusion. Conclusion: A substantial proportion of NSTEMI patients harbor total or near total coronary artery occlusion. Elevated troponin, high-risk clinical scores, smoking, and specific ECG changes may help identify NSTEMI patients who would benefit from early invasive strategies. Keywords: NSTEMI; Coronary artery occlusion; TIMI score; Troponin; Risk stratification; STEMI equivalents.