Clinical characteristics and outcome in patients with a delayed presentation after ST-elevation myocardial infarction and complicated by cardiogenic shock

Sex differences in treatments and outcomes of patients with cardiogenic shock: a systematic review and epidemiological meta-analysis

BACKGROUND

Women are at higher risk of mortality from many acute cardiovascular conditions, but studies have demonstrated differing findings regarding the mortality of cardiogenic shock in women and men. To examine differences in 30-day mortality and mechanical circulatory support use by sex in patients with cardiogenic shock.

MAIN BODY

Cochrane Central, PubMed, MEDLINE and EMBASE were searched in April 2024. Studies were included if they were randomised controlled trials or observational studies, included adult patients with cardiogenic shock, and reported at least one of the following outcomes by sex: raw mortality, adjusted mortality (odds ratio) or use of mechanical circulatory support. Out of 4448 studies identified, 81 met inclusion criteria, pooling a total of 656,754 women and 1,018,036 men. In the unadjusted analysis for female sex and combined in-hospital and 30-day mortality, women had higher odds of mortality (Odds Ratio (OR) 1.35, 95% confidence interval (CI) 1.26-1.44, p < 0.001). Pooled unadjusted mortality was 35.9% in men and 40.8% in women (p < 0.001). When only studies reporting adjusted ORs were included, combined in-hospital/30-day mortality remained higher in women (OR 1.10, 95% CI 1.06-1.15, p < 0.001). These effects remained consistent across subgroups of acute myocardial infarction- and heart failure- related cardiogenic shock. Overall, women were less likely to receive mechanical support than men (OR = 0.67, 95% CI 0.57-0.79, p < 0.001); specifically, they were less likely to be treated with intra-aortic balloon pump (OR = 0.79, 95% CI 0.71-0.89, p < 0.001) or extracorporeal membrane oxygenation (OR = 0.84, 95% 0.71-0.99, p = 0.045). No significant difference was seen with use of percutaneous ventricular assist devices (OR = 0.82, 95% CI 0.51-1.33, p = 0.42).

CONCLUSION

Even when adjusted for confounders, mortality for cardiogenic shock in women is approximately 10% higher than men. This effect is seen in both acute myocardial infarction and heart failure cardiogenic shock. Women with cardiogenic shock are less likely to be treated with mechanical circulatory support than men. Clinicians should make immediate efforts to ensure the prompt diagnosis and aggressive treatment of cardiogenic shock in women.

Factors Responsible for Worse Outcomes in STEMI Patients With Early vs Delayed Treatment Presenting in a Tertiary Care Center in a Third World Country

The aim of the study is to compare the outcomes among ST-segment elevation myocardial infarction (STEMI) cases with early treatment vs delayed treatment. It was a prospective comparative study on 186 patients with consecutive (nonprobability) sampling. Two groups of cases were made as per their time to get admitted to the hospital (ie, within 2 hours of symptom onset = Group A; after 2 hours of symptom onset = Group B). Patients were asked for factors causing a delay in treatment after the onset of symptoms and were monitored for STEMI outcomes. The mean age of all patients was 46.62 ± 9.76 years and there were 140 (75.27%) male and 46 (24.73%) female, and male to female ratio 3:1.Factors significant for delayed treatment vs nondelayed treatment were poor social economic status (65.6% vs 20.4%), history of chronic stable angina (33.3% vs 11.8%), delayed response in the emergency room (20.4% vs 8.6%), delayed ECG acquisition (26.9% vs 8.6%), delayed ECG interpretation (25.8% vs 4.3%), pain at night 12:00-6:00 AM (21.5% vs 9.7%) and belief that the chest pain is noncardiac (26.9% vs 3.2%). Acute heart failure was significantly greater in group B (9.7%) in comparison with group A (2.2%), re-infarction was 18.3% in group B in comparison with 7.5% group A. Similarly sustained ventricular tachycardia and ventricular fibrillation and in-hospital mortality were higher in group B (12.9%, 14%, and 12.9% respectively). Due to delayed treatment patients had higher hospital stays, and complications, like acute heart failure, re-infarction, ventricular fibrillation, and in-hospital mortality.

Acute mechanical circulatory support for cardiogenic shock in India

Cardiogenic shock continues to have high morbidity and mortality, despite advances in the field. Temporary mechanical circulatory support (TMCS) devices, if instituted in a timely fashion, can help stabilize critically ill patients with cardiogenic shock from various aetiologies and cardiac arrest, and provide time for organ recovery or till durable support or transplantation can be achieved. Currently, several options for TMCS devices exist. In this review, we discuss indications, contraindications, characteristics of the various available devices, and important issues pertaining to their management.

Regional differences in presentation characteristics, use of treatments and outcome of patients with cardiogenic shock: Results from multicenter, international registry

BACKGROUND

Concurrent evidence about cardiogenic shock (CS) characteristics, treatment and outcome does not represent a global spectrum of patients and is therefore limited. The aim of this study was to investigate these regional differences.

METHODS

To investigate regional differences in presentation characteristics, treatments and outcomes of patients treated with all types of cardiogenic shock (CS) in a single calendar year on a multi-national level. Consecutive patients from 19 tertiary care hospitals in 13 countries with CS who were treated between January 1, 2018 and December 31, 2018 were enrolled in this study.

RESULTS

In total, 699 cardiogenic shock patients were included in this study. Of these patients, 440 patients (63%) were treated in European hospitals and 259 (37%) were treated in Non-European hospitals. Female patients (P<0.01) and patients with a previous myocardial infarction (P=0.02) were more likely to present at Non-European hospitals; whereas older patients (P=0.01) and patients with cardiogenic shock due to acute heart failure (P<0.01) were more likely to present at European hospitals. Vasopressor use was more likely in Non-European hospitals (P=0.04), whereas use of mechanical circulatory support (MCS) was more likely in European hospitals (P<0.01). Despite adjustment for relevant confounders, 30-day in-hospital mortality risk was comparably high in CS patients treated in European vs. Non-European hospitals (hazard ratio 1.08, 95% CI 0.84-1.39, P=0.56).

CONCLUSION

Despite marked heterogeneity in characteristics and treatment of CS patients, including fewer use of MCS but more frequent use of vasopressors in Non-European hospitals, 30-day in-hospital mortality did not differ between regions.

Acute coronary syndrome treatment delay in low to middle-income countries: A systematic review

Although morbidity and mortality rates are declining for acute coronary syndrome (ACS) in most high-income countries, it is rising at an alarming pace for low to middle income countries (LMICs). A major factor that is contributing to the poor clinical outcomes among LMICs is largely due to prehospital treatment delays. This systematic review was conducted to determine the mean length of time from symptom onset to treatment in LMICs and the sociodemographic, clinical and health system characteristics that contribute to treatment delays. We conducted a comprehensive review of the relevant literature published in English between January 1990 through May 2020 using predefined inclusion and exclusion criteria. Twenty-nine studies were included and time to treatment was defined from ACS symptom onset to first medical contact and dichotomized further as less than or >12-hours. The mean time from symptom onset to first medical contact was 12.7 h which ranged from 10-minutes to 96 h. There was consensus among studies that being older, female, illiterate, living in a rural area, and financially limited was associated with longer treatment delays. Lack of a developed emergency transportation system, poor communication and organization between community facilities and interventional facilities were also cited as major contributors for ACS treatment delays. Findings from this systematic review provide future directions to potentially reduce prehospital delays in LMICs and improve ACS outcomes.

Cardiovascular manifestations of COVID-19: An evidence-based narrative review

The recent outbreak of coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, primarily involves the respiratory system with viral pneumonia as a predominant manifestation. In addition, SARS-CoV-2 has various cardiovascular manifestations which increase morbidity and mortality in COVID-19. Patients with underlying cardiovascular diseases and conventional cardiovascular risk factors are predisposed for COVID-19 with worse prognosis. The possible mechanisms of cardiovascular injury are endothelial dysfunction, diffuse microangiopathy with thrombosis and increased angiotensin II levels. Hyperinflammation in the myocardium can result in acute coronary syndrome, myocarditis, heart failure, cardiac arrhythmias and sudden death. The high level of cardiac troponins and natriuretic peptides in the early course of COVID-19 reflects an acute myocardial injury. The complex association between COVID-19 and cardiovascular manifestations requires an in-depth understanding for appropriate management of these patients. Till the time a specific antiviral drug is available for COVID-19, treatment remains symptomatic. This review provides information on the cardiovascular risk factors and cardiovascular manifestations of COVID-19.

Comparison of demographic profile, risk factors, and in-hospital outcome in young and old patients with acute coronary syndrome: A single-center experience

Background:

Coronary artery disease (CAD) is witnessing a demographic transition with increasing prevalence in younger individuals. Data is scarce comparing various characteristics of acute coronary syndrome (ACS) between young and old patients in an Indian setting. Hence, we evaluated the epidemiological, demographic, risk factor, and outcome profile of young and old ACS patients in Indian setting.

Methods:

This was a prospective observational study, which enrolled 50 consecutive ACS patients each into two groups: younger (≤45 years) and elderly (>45 years), respectively. Comparison of clinical presentation, electrocardiography, echocardiographic findings, conventional, nonconventional risk factors, and in-hospital outcomes including duration of hospital stay and major adverse cardiac events (MACE) were made between the two groups. Multivariate regression analysis of risk factors as determinants of MACE adjusting for other confounding factors was also performed.

Results:

Fifty patients in each group were compared. Mean age in the younger and elderly group was 36 ± 4.69 and 61.58 ± 10.69 years, respectively. Male sex, smoking, family history of CAD, hyperhomocysteinemia, and obesity were observed more in the younger population. While dyslipidemia, low physical activity, diabetes mellitus, and history of previous ACS was more in the older population. Single-vessel disease was more common in younger patients while multivessel involvement was more common in elderly patients. Older patients had longer hospital stays and more in-hospital MACE including deaths. By multivariate analysis, shock was found to be an independent predictor of MACE in both groups.

Conclusion:

Younger ACS patients have a different risk profile and better in-hospital outcomes compared to older patients.

Prognostic role of procalcitonin in ST-elevation myocardial infarction complicated by cardiogenic shock

OBJECTIVE

Cardiogenic shock accounts for the majority of deaths amongst patients with ST-elevation myocardial infarction. Procalcitonin is elevated in acute myocardial infarction, especially when complicated by left heart failure, cardiogenic shock, resuscitated cardiac arrest, and bacterial infections. However, the prognostic utility of procalcitonin in ST-elevation myocardial infarction complicated by cardiogenic shock has not been systematically evaluated.

METHODS

We performed a retrospective registry review of 125 patients with ST-elevation myocardial infarction and cardiogenic shock over 2 years at a tertiary referral hospital to examine the prognostic value of serum procalcitonin measurement at 24 hours after the onset of infarction for in-hospital mortality.

RESULTS

The mean age of the study population was 57.75 ± 11.1 years, and the median delay from onset to hospital admission was 15 hours. The in-hospital mortality was 28.8%. Receiver operating characteristic analysis revealed a strong relationship between elevated procalcitonin and in-hospital mortality (area under the curve = 0.676; p = 0.002). Although procalcitonin was found to be higher in non-survivors in univariate analysis, it was not an independent predictor of mortality in multivariate regression analysis. Acute kidney injury, left ventricular ejection fraction, and non-revascularization were independently associated with mortality after adjusting for covariates.

CONCLUSION

Although procalcitonin was higher in non-survivors, static procalcitonin measurement at 24 hours after the onset of ST-elevation myocardial infarction complicated by cardiogenic shock was not an independent predictor of in-hospital mortality. Additional prospective studies are required to assess the role of serial procalcitonin monitoring in ST-elevation myocardial infarction complicated by cardiogenic shock.

Epidemiological profile, management and outcomes of patients with acute coronary syndrome: Single centre experience from a tertiary care hospital in North India

Background

Cardiovascular disease is the leading cause of death in India. Our aim is to study the clinical, epidemiological profile and in-hospital outcomes of patients presenting with acute coronary syndrome.

Methods

We did a prospective single center observational study of the 1203 patients presenting with ACS to a tertiary referral center in North India over a period of one year (July 2018–June 2019).

Results

The mean age of study population was 58.4 ± 12.5 years. STEMI and NSTE-ACS accounted for 69.9% and 31.1% respectively. 62.1% of our patients were from rural background. The median time to hospital admission was 600 min for STEMI patients, thrombolysis was performed in 52% of cases. Cardiogenic shock at presentation was noted in 18%. Coronary angiography and percutaneous coronary intervention were done in 1062 (88.3%) and 733 (60.9%) patients respectively. The overall in-hospital mortality was 7.6%. STEMI patients had higher mortality than NSTE-ACS (8.9% vs 4.5% p < 0.001). Female gender (OR−3.306 C.I. 1.87–5.845), severe MR (OR−4.65, C.I.−1.187–18.18), acute kidney injury (AKI) at admission (OR-5.15, C.I.−2.5–10.63), higher Killip class (class III/IV) (OR−3.378,C.I.−1.292–8.849), AF (OR−3.25, C.I.−1,18–8.92), complete heart block (CHB) (OR−4.44,C.I.−2.09–9.43) and right bundle branch block (RBBB) (OR−2.86, C.I.−1.2–6.8) were significant predictors of in hospital mortality.

Conclusions

Our study represents the predominance of STEMI as the initial ACS presentation with a considerable delay in first medical contact and higher prevalence of cardiogenic shock (CS). STEMI patients had higher mortality. Female sex, severe MR, AKI, higher Killips class, AF, CHB, RBBB being predictors of high in-hospital mortality in ACS patients.

Role of N-terminal pro-B-type natriuretic peptide in the prediction of outcomes in ST-elevation myocardial infarction complicated by cardiogenic shock

Although measurements of natriuretic peptides have a role in chronic heart failure and acute coronary syndrome, their role has not been studied in ST-elevation myocardial infarction complicated by cardiogenic shock (CS-STEMI). Sixty-four patients with CS-STEMI were prospectively recruited to assess the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement after 24 h of the onset of angina or anginal equivalent. Patients who died within 24 h were excluded. The mean age was 56.9 ± 10.6 years and the median time to presentation was 22 h (Interquartile range 7–48 h). Thrombolysis was done in 51% and PCI in 31% of cases. The in-hospital mortality was 26.5%. The ROC analysis showed a strong relationship between elevated NT-proBNP and in-hospital mortality (AUC = 0.748; p = 0.003). An NT-proBNP value > 8582 pg/mL showed 76.5% sensitivity, 68% specificity, 46.4% positive predictive value, and 89% negative predictive value for in-hospital mortality. Acute kidney injury [Odds ratio (OR) 7.30; 95% confidence interval (CI) 1.42–37.37] and NT-proBNP (OR 1.12 per 1000 pg/mL; CI 1.012–1.25) were independent predictors of mortality in multivariate regression analysis. Although we found plasma NT-proBNP at 24 h to be an independent predictor of in-hospital mortality in CS-STEMI, additional studies with a larger sample are required to ascertain these findings and validate the appropriate cut-off values.