Temporal Trends in Cardiogenic Shock Treatment and Outcomes Among Ontario Patients With Myocardial Infarction Between 1992 and 2008

Long-Term Outcomes of Cardiogenic Shock Complicating Myocardial Infarction

BACKGROUND

Cardiogenic shock secondary to acute myocardial infarction (AMI-CS) is associated with substantial short-term mortality; however, there are limited data on long-term outcomes and trends.

OBJECTIVES

This study sought to examine long-term outcomes of AMI-CS patients.

METHODS

This was a population-based, retrospective cohort study in Ontario, Canada of critically ill adult patients with AMI-CS who were admitted to hospitals between April 1, 2009 and March 31, 2019. Outcome data were captured using linked health administrative databases.

RESULTS

A total of 9,789 consecutive patients with AMI-CS from 135 centers were included. The mean age was 70.5 ± 12.3 years, and 67.7% were male. The incidence of AMI-CS was 8.2 per 100,000 person-years, and it increased over the study period. Critical care interventions were common, with 5,422 (55.4%) undergoing invasive mechanical ventilation, 1,425 (14.6%) undergoing renal replacement therapy, and 1,484 (15.2%) receiving mechanical circulatory support. A total of 2,961 patients (30.2%) died in the hospital, and 4,004 (40.9%) died by 1 year. Mortality at 5 years was 58.9%. Small improvements in short- and long-term mortality were seen over the study period. Among survivors to discharge, 2,870 (42.0%) required increased support in care from their preadmission baseline, 3,244 (47.5%) were readmitted to the hospital within 1 year, and 1,047 (15.3%) died within 1 year. The mean number of days at home in the year following discharge was 307.9 ± 109.6.

CONCLUSIONS

Short- and long-term mortality among patients with AMI-CS is high, with minimal improvement over time. AMI-CS survivors experience significant morbidity, with high risks of readmission and death. Future studies should evaluate interventions to minimize postdischarge morbidity and mortality among AMI-CS survivors.

HOSPITAL CHARACTERISTICS ARE ASSOCIATED WITH CLINICAL OUTCOMES IN PATIENTS WITH CARDIOGENIC SHOCK

ABSTRACT

Background: Regionalized systems of care for the management of cardiogenic shock (CS) are increasingly being utilized. This study aims to assess whether receiving hospital characteristics such as the availability of 24-hour coronary angiography, on-site cardiac surgery, and annual treated CS volume influence outcomes in patients transferred by emergency medical services (EMS) to hospital with CS. Methods: This population-based cohort study included consecutive adult patients with CS who were transferred to hospital by EMS between January 1, 2015 and June 30, 2019 in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. The primary outcome assessed was 30-day mortality stratified by the availability of 24-hour coronary angiography (cardiac center) at the receiving hospital. Results: A total of 3,217 patients were transferred to hospital with CS. The population had an average age of 67.9 +/- 16.1 years, and 1,289 (40.1%) were female. EMS transfer to a cardiac center was associated with significantly reduced rates of 30-day mortality (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.64-0.95), compared with noncardiac centers. Compared with the lowest annual CS volume quartile (<18 cases per year), hospitals in the highest volume quartile (>55 cases per year) had reduced risk of 30-day mortality (aOR, 0.71; 95% CI, 0.56-0.91). A stepwise reduction in the adjusted probability of 30-day mortality was observed in patients transferred by EMS to trauma level 1 centers (34.6%), compared with cardiothoracic surgical centers (39.0%), noncardiac surgical metropolitan (44.9%), and rural (51.3%) cardiac centers, all P < 0.05. Conclusion: Receiving hospital characteristics are associated with survival outcomes in patients with CS. These finding have important implications for establishing regionalized systems of care for patients with CS who are transferred to hospital by EMS.

Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

BACKGROUND

Despite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated.

METHODS

We analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality.

RESULTS

Among 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, P < 0.01). Considering data available at FMC, CS patients with a combination of age ≥76 years, anterior STEMI and an expected ischemia time > 3 h and 21 min were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045-1,141; P = 0.003), final TIMI flow 2-3 (OR 0.058; 95% CI 0.004-0.785; P = 0.032) and Ischemia Time (OR = 1.269; 95% CI 1.001-1.609; P = 0.049) were independently associated with 30-day mortality.

CONCLUSIONS

In a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.

Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction: An 18-Year Analysis of Temporal Trends, Epidemiology, Management, and Outcomes

BACKGROUND

There are limited data on the temporal trends, incidence, and outcomes of ST-segment-elevation myocardial infarction-cardiogenic shock (STEMI-CS).

METHODS

Adult (>18 years) STEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011, 2012-2017). Outcomes of interest included temporal trends, acute organ failure, cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay.

RESULTS

In ∼4.3 million STEMI admissions, CS was noted in 368,820 (8.5%). STEMI-CS incidence increased from 5.8% in 2000 to 13.0% in 2017 (patient and hospital characteristics adjusted odds ratio [aOR] 2.45 [95% confidence interval {CI} 2.40-2.49]; P < 0.001). Multiorgan failure increased from 55.5% (2000-2005) to 74.3% (2012-2017). Between 2000 and 2017, coronary angiography and percutaneous coronary intervention use increased from 58.8% to 80.1% and 38.6% to 70.6%, whereas coronary artery bypass grafting decreased from 14.9% to 10.4% (all P < 0.001). Over the study period, the use of intra-aortic balloon pump (40.6%-37.6%) decreased, and both percutaneous left ventricular assist devices (0%-12.9%) and extra-corporeal membrane oxygenation (0%-2.8%) increased (all P < 0.001). In hospital mortality decreased from 49.6% in 2000 to 32.7% in 2017 (aOR 0.29 [95% CI 0.28-0.31]; P < 0.001). During the 18-year period, hospital lengths of stay decreased, hospitalization costs increased and use of durable left ventricular assist device /cardiac transplantation remained stable (P > 0.05).

CONCLUSIONS

In the United States, incidence of CS in STEMI has increased 2.5-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and PCI increased during the study period.

Sex bias in admission to tertiary-care centres for acute myocardial infarction and cardiogenic shock

BACKGROUND

There are limited data on sex-specific outcomes and management of cardiogenic shock complicating ST-segment elevation myocardial infarction (CS-STEMI). We investigated whether any sex bias exists in the admission to revascularization capable hospitals (RCH) or intensive cardiac care units (ICCU) and its impact on in-hospital mortality.

METHODS

We used the Spanish National Health System Minimum Basic Data from 2003 to 2015 to identify patients with CS-STEMI. The primary outcome was sex differences in in-hospital mortality.

RESULTS

Among 340 490 STEMI patients, 20 262 (6%) had CS and 29.2% were female. CS incidence was higher in women than in men (7.9% vs 5.1%, P = .001). Women were older and had more hypertension and diabetes, and were less often admitted to RCH than men (from 58.7% in 2003 to 79.6% in 2015; and from 61.9% in 2003 to 85.3% in 2015; respectively, P = .01), and to ICCU centres (25.7% vs 29.2%, P = .001). Adjusted mortality was higher in women than men over time (from 79.5 ± 4.3% to 65.8 ± 6.5%; and from 67.8 ± 6% to 58.1 ± 6.5%; respectively, P < .001). ICCU availability was associated with higher use of Percutaneous coronary intervention (PCI) in women (46.8% to 67.2%; P < .001) but was even higher in men (54.8% to 77.4%; P < .001). In ICCU centres, adjusted mortality rates decreased in both sexes, but lower in women (from 74.9 ± 5.4% to 66.3 ± 6.6%) than in men (from 67.8 ± 6.0% to 58.1 ± 6.5%, P < .001). Female sex was an independent predictor of mortality (OR 1.18 95% CI 1.10-1.27, P < .001).

CONCLUSIONS

Women with CS-STEMI were less referred to tertiary-care centres and had a higher adjusted in-hospital mortality than men.

Sex differences in acute cardiovascular care: a review and needs assessment

Despite significant progress in the care of patients suffering from cardiovascular disease, there remains a persistent sex disparity in the diagnosis, management, and outcomes of these patients. These sex disparities are seen across the spectrum of cardiovascular care, but, are especially pronounced in acute cardiovascular care. The spectrum of acute cardiovascular care encompasses critically ill or tenuous patients with cardiovascular conditions that require urgent or emergent decision-making and interventions. In this narrative review, the disparities in the clinical course, management, and outcomes of six commonly encountered acute cardiovascular conditions, some with a known sex-predilection will be discussed within the basis of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where improvement in clinical approaches are needed.

Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

BACKGROUND

Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock.

OBJECTIVES

The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality.

METHODS

We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS).

RESULTS

Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53).

CONCLUSIONS

This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.

Trends in the management and outcomes of patients admitted with acute coronary syndrome complicated by cardiogenic shock over the past decade: Real world data from the acute coronary syndrome Israeli survey (ACSIS)

Registries and other cohorts have demonstrated that early revascularization improve the survival of patients presenting with Cardiogenic Shock (CS) completing Aute coronary syndrome (ACS). Our aim was to describe the change in the clinical characteristics of these patients and their management and their outcome. The study population comprised 224 patients who were admitted with ACS complicated by cardiogenic shock who were enrolled in the prospective biannual Acute Coronary Syndrome Israeli Surveys (ACSIS) between 2000 and 2013 (1.7% of all patients admitted with ACS during the study period). Survey periods were categorized as early (years 2000-2004) and late (year 2006-2013).

The rate of cardiogenic shock complicated ACS declined from 1.8% between the years 2000-2004 to 1.5% during the years 2006-2013. The clinical presentation in both the early and late groups was similar. During the index hospitalization primary percutaneous coronary intervention (PPCI) was more frequently employed during the late surveys [31% vs. 58% (p<0.001)], while fibrinolysis therapy was not used in the late surveys group [27% vs. 0.0% (p=<0.001)]. Compared to patients enrolled in the early surveys, those enrolled in the late survey group experienced significantly lower mortality rates at 7-days (44% vs. 30%, respectively; p=0.03). However, this difference was no longer statistically significant at 30-days (52.8% vs. 46.4%, respectively, p=0.34) and 1-year (63% vs. 53.2%, respectively, p=0.14). Similarly, the rate of major adverse cardiac events (MACE) at 30-days was similar between the two groups (57.4% vs. 47.4%, respectively, p=0.13).

Our findings indicate that patients admitted with ACS complicated by cardiogenic shock still experience very high rates of MACE and mortality during follow-up, despite a significant increase in the use of PPCI in this population over the past decade.

Temporal trends in clinical characteristics and management according to sex in patients with cardiogenic shock after acute myocardial infarction: The FAST-MI programme

BACKGROUND

Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) occurs more frequently in women, but little is known about its potential specificities according to sex.

AIMS

To analyse the incidence, management and 1-year mortality of CS according to sex using the FAST-MI programme.

METHODS

The FAST-MI programme consists of four nationwide French surveys carried out 5 years apart from 1995 to 2010, including consecutive patients with AMI over a 1-month period, and with a 1-year follow-up.

RESULTS

Among the 10,610 patients included in the surveys, the incidence of CS was 4.8% in men and 8.2% in women (P<0.001). Absolute incidence of CS decreased from 1995 to 2010 in both sexes. Mean age in patients with CS tended to decrease in men (from 72±12 to 69±13 years) and to increase in women (from 78±10 to 80±9 years). One-year mortality decreased significantly in men (from 70% in 1995 to 48% in 2010) and in women (from 81% to 54%). Using Cox multivariable analysis, female sex was not an independent correlate of 1-year mortality [hazard ratio (HR): 0.98, 95% confidence interval (CI): 0.78-1.22]. Early use of percutaneous coronary intervention was, however, an independent predictor of 1-year survival in women (HR: 0.55, 95% CI: 0.37-0.81), but showed only a non-significant trend in men (HR: 0.85, 95% CI: 0.61-1.19).

CONCLUSIONS

The incidence of CS-AMI has decreased in both men and women, but remains higher in women. One-year mortality has significantly decreased for both men and women, and the role of early percutaneous coronary intervention as a potential mediator of decreased mortality seems greater in women than in men.

Decade-Long Trends (2001-2011) in the Incidence and Hospital Death Rates Associated with the In-Hospital Development of Cardiogenic Shock after Acute Myocardial Infarction

BACKGROUND

Limited information is available about relatively contemporary trends in the incidence and hospital case-fatality rates of cardiogenic shock in patients hospitalized with acute myocardial infarction. The purpose of this population-based study was to describe decade long trends (2001-2011) in the incidence and hospital case-fatality rates for patients who developed cardiogenic shock during hospitalization for an acute myocardial infarction.

METHODS AND RESULTS

The study population consisted of 5686 residents of central Massachusetts hospitalized with acute myocardial infarction at all 11 medical centers in the Worcester, MA, metropolitan area during 6 biennial periods between 2001 and 2011, who did not have cardiogenic shock at the time of hospital presentation. On average, 3.7% of these patients developed cardiogenic shock during their acute hospitalization with nonsignificant and inconsistent trends noted over time in both crude (3.7% in 2001/2003; 4.5% in 2005/2007; 2.7% in 2009/2011; P=0.19) and multivariable adjusted analyses. The overall in-hospital case-fatality rate for patients who developed cardiogenic shock was 41.4%. The crude and multivariable adjusted odds of dying after cardiogenic shock declined during the most recent study years (47.1% dying in 2001/2003, 42.0% dying in 2005/2007, and 28.6% dying in 2009/2011). Increases in the use of evidence-based cardiac medications, and interventional procedures paralleled the increasing hospital survival trends.

CONCLUSIONS

We found suggestions of a decline in the death, but not incidence, rates of cardiogenic shock over time. These encouraging trends in hospital survival are likely because of advances in the early recognition and aggressive management of patients who develop cardiogenic shock.

Temporal trends in the use of intraaortic balloon pump associated with percutaneous coronary intervention in the United States, 1998-2008

BACKGROUND

With conflicting evidence regarding the usefulness of intraaortic balloon pump (IABP), reports of IABP use in the United States have been inconsistent. Our objective was to examine trends in IABP usage in percutaneous coronary intervention (PCI) in the United States and to evaluate the association of IABP use with mortality.

METHODS

This is a retrospective, observational study using patient data obtained from the Nationwide Inpatient Sample database from 1998 to 2008. Patients undergoing any PCI (1,552,602 procedures) for a primary diagnosis of symptomatic coronary artery disease and acute coronary syndrome, including non-ST-elevation myocardial infarction and ST-elevation myocardial infarction, were evaluated.

RESULTS

The overall use of IABP significantly decreased during the study period from 0.99% in 1998 to 0.36% in 2008 (univariate and multivariate P for trend < .0001). Patients who received IABP had substantially higher rates of shock compared with those who did not receive IABP (38.09% vs 0.70%; P < .0001), which was associated with markedly higher inhospital mortality rates (20.31% vs 0.72%; P < .0001). However, IABP use significantly decreased in patients with shock (36.5%-13.4%) and acute myocardial infarction (2.23%-0.84%) (univariate and multivariate P for trend for both < .0001). A temporal reduction in all-cause PCI-associated mortality from 1.1% in 1998 to 0.86% in 2008 (univariate and multivariate P for trend < .0001) was also observed.

CONCLUSIONS

The utilization of IABP associated with PCI significantly decreased between 1998 and 2008 in the United States, even among patients with acute myocardial infarction and shock.

Characteristics and outcomes in patients undergoing percutaneous coronary intervention following cardiac arrest (from the NCDR)

Outcomes in patients with out-of-hospital cardiac arrest (CA) who undergo percutaneous coronary intervention (PCI) have been limited to small, mostly single-center studies. We compared patients who underwent PCI after CA included in the CathPCI Registry with those without CA. Patients with ST elevation were classified as ST-elevation myocardial infarction (STEMI); all other patients having PCI were classified as without STEMI. Patients with CA in each group were compared with the corresponding non-CA groups for baseline characteristics, angiographic findings, and outcomes. A total of 594,734 patients underwent PCI, of whom 114,768 had STEMI, including 9,375 (8.2%) had CA, and 479,966 had without STEMI, including 2,775 (0.6%) had CA. Patients with CA were similar in age to patients with non-CA, with a lower frequency of coronary disease risk factors and known coronary disease. On angiography, patients with CA were significantly more likely to have more complex lesions with worse baseline thrombolysis in myocardial infarction flow. Patients with CA were significantly more likely to have cardiogenic shock, both for patients with STEMI (51% vs 7.2%, respectively) and for patients without STEMI (38% vs 0.8%, respectively, both p<0.001). In-hospital mortality was substantially worse in patients with CA, for both patients with STEMI (24.9% vs 3.1%, respectively) and patients without STEMI (18.7% vs 0.4%, respectively). In conclusion, patients who underwent PCI after CA had more complex anatomy, more shock, and higher mortality. The substantially increased mortality in patients with CA has important implications for the development and regionalization of centers for CA.

Differences in the profile, treatment, and prognosis of patients with cardiogenic shock by myocardial infarction classification: A report from NCDR

BACKGROUND

Cardiogenic shock is a deadly complication of an acute myocardial infarction (MI). We sought to characterize differences in patient features, treatments, and outcomes of cardiogenic shock by MI classification: ST-segment-elevation MI (STEMI) versus non-ST-segment elevation MI (NSTEMI).

METHODS AND RESULTS

We compared differences in care by the shock status of 235 541 patients with STEMI and NSTEMI treated at 392 US hospitals from 2007 to 2011. Cardiogenic shock occurred in 12.2% of patients with STEMI versus 4.3% of patients with NSTEMI. Compared with STEMI shock, NSTEMI shock was more likely in patients who were older and predominantly women; had diabetes mellitus, hypertension, previous heart failure, MI, or peripheral arterial disease; and who received coronary artery bypass grafting (11.6% versus 21.2%; P<0.0001) but less likely to have received percutaneous coronary intervention (84.2% versus 35.3%; P<0.0001). Compared with patients with STEMI presenting with shock at admission, patients with NSTEMI presenting with shock had longer delays to percutaneous coronary intervention (1.2 versus 3.2 hours) and coronary artery bypass grafting (7.9 versus 55.9 hours). Cardiogenic shock in patients with STEMI was associated with a lower mortality risk (33.1% shock versus 2.0% no shock; adjusted odds ratio, 14.1; 95% confidence interval, 13.0-15.4; interaction P value <0.0001) compared with patients with NSTEMI (40.8% shock versus 2.3% no shock, odds ratio, 19.0; 95% confidence interval, 17.1-21.2).

CONCLUSIONS

Cardiogenic shock is associated with high mortality in patients with STEMI and NSTEMI. However, urgent revascularization is more commonly pursued in patients with STEMI presenting with shock than in patients with NSTEMI. More research is needed to improve the outcomes for patients with MI presenting with shock, particularly those presenting with NSTEMI.

Heart rescue: the role of mechanical circulatory support in the management of severe refractory cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock is present in 3.5% of patients presenting with acute decompensated heart failure. Despite advances in therapy, mortality remains high, approaching 70% in some settings. Recent management strategies have incorporated the use of mechanical circulatory support (MCS), which has been associated with better survival in nonrandomized trials. MCS is increasingly used in the acute setting and has become an important treatment modality for cardiogenic shock.

RECENT FINDINGS

Small studies have demonstrated improved survival when MCS is instituted early in the management of cardiogenic shock. Numerous case reports support the benefit of MCS for various causes of cardiogenic shock, including acute myocardial infarction, cardiac allograft rejection, myocarditis and refractory arrhythmias.

SUMMARY

This article will review novel strategies in the management of cardiogenic shock including percutaneous MCS (intra-aortic balloon pump, Impella, TandemHeart, venoarterial extracorporeal membrane oxygenation) and surgically implanted devices (CentriMag) that are used for short-term management. We will review the mechanisms involved in cardiogenic shock and discuss management and device selection strategies.

Sex differences in the management and outcomes of Ontario patients with cardiogenic shock complicating acute myocardial infarction

BACKGROUND

Sex differences in the management of acute myocardial infarction (AMI) patients with cardiogenic shock (CS) have not been well studied.

METHODS

We examined mortality and revascularization rates of 9750 patients with CS between 1992 and 2008 in the Ontario Myocardial Infarction Database. Men and women were compared in the entire cohort and in subgroups divided by age (aged < 75 years vs aged ≥ 75 years) and revascularization availability at presenting hospital. Logistic regression was used to determine the adjusted effect of sex on mortality and to determine predictors of revascularization.

RESULTS

The incidence of CS was higher in women (3.7% of female vs 2.7% of male AMI patients; P < 0.001). Women with CS were older than men (mean age: 75.5 vs 71.1 years; P < 0.001) and less likely to present to revascularization-capable sites (16% vs 19.2%; P < 0.001). Unadjusted 1-year mortality rates were higher in women (80.3% vs 75.4%; P < 0.001). Women were less likely to be revascularized (12.6% vs 17.6%; P < 0.001) and less likely to be transferred when they presented to nonrevascularization sites (11.3% vs 14.2%; P < 0.001). The strongest predictor of revascularization was presentation to a revascularization-capable site (odds ratio, 17.69; P < 0.001). After regression adjustment, there were no significant differences in mortality or revascularization between the sexes.

CONCLUSION

Women with CS are older than men with CS and are less likely to present to revascularization-capable sites. This accounts for the lower unadjusted revascularization rates among women compared with men. However, there are no significant sex-based differences in adjusted mortality rates.

Improved outcome of cardiogenic shock at the acute stage of myocardial infarction: a report from the USIK 1995, USIC 2000, and FAST-MI French nationwide registries

AIM

The historical evolution of incidence and outcome of cardiogenic shock (CS) in acute myocardial infarction (AMI) patients is debated. This study compared outcomes in AMI patients from 1995 to 2005, according to the presence of CS.

METHOD AND RESULTS

Three nationwide French registries were conducted 5 years apart, using a similar methodology in consecutive patients admitted over a 1-month period. All 7531 AMI patients presenting ≤48 h of symptom onset were included. The evolution of mortality was compared in the 486 patients with CS vs. those without CS. The incidence of CS tended to decrease over time (6.9% in 1995; 5.7% in 2005, P = 0.07). Thirty-day mortality was considerably higher in CS patients (60.9 vs. 5.2%). Over the 10-year period, mortality decreased for both patients with (70-51%, P = 0.003) and without CS (9-4%, P < 0.001). In CS patients, the use of percutaneous coronary intervention (PCI) increased from 20 to 50% (P < 0.001). Time period was an independent predictor of early mortality in CS patients (OR for death, 2005 vs. 1995 = 0.45; 95% CI: 0.27-0.75, P = 0.005), along with age, diabetes, and smoking status. When added to the multivariate model, PCI was associated with decreased mortality (OR = 0.38; 95% CI: 0.24-0.58, P < 0.001). In propensity-score-matched cohorts, CS patients with PCI had a significantly higher survival.

CONCLUSIONS

Cardiogenic shock remains a clinical concern, although early mortality has decreased. Improved survival is concomitant with a broader use of PCI and recommended medications at the acute stage. Beyond the acute stage, however, 1-year survival has remained unchanged.