Real-World Interventional Outcomes for Cardiogenic Shock Complicating Acute Myocardial Infarction
Poster #: 088
Session/Time: A
Author:
Zachary Bouker, MS
Mentor:
John E Brush, MD
Research Type: Clinical Research
Abstract
INTRODUCTION:
Acute myocardial infarction with cardiogenic shock continues to be a major concern. Cardiogenic shock (CS) occurs in 10% of patients with ST-elevation acute myocardial infarction (STEMI) and is associated with a 30-day mortality of approximately 40%. With persistently high mortality rates, clinicians use interventions with marginal benefit and some evidence of harm. In this study, we examined the outcomes among AMICS patients treated with mechanical circulatory support (MCS) using a micro-axial left ventricular assist device and intra-aortic balloon counter-pulsation (IABP).
METHODS:
This observational study utilized the Cath PCI Registry v4.4/5.0 from the NCDR, with data augmented by the Xper Information Management System and Sentara EHR. We included patients undergoing acute PCI for STEMI from January 1, 2017, to December 31, 2022, and identified 505 patients with cardiogenic shock across 8 hospitals using registry coding. Primary outcomes were 30 and 180-day mortality, with secondary outcomes including in-hospital complications such as major bleeding, vascular access site injury, new requirement for dialysis, stroke, and sepsis. Statistical analysis was performed with an emphasis of comparing outcomes between 160 patients treated with IABP and 73 patients treated with MCS, as well as outcomes between MCS-inclined and IABP-inclined hospitals.
RESULTS:
Of the 505 AMICS patients, 73 were treated with MCS and 160 with IABP. Baseline characteristics were similar between treatment groups except infarct location. 34 (46.6%) of the 73 patients treated with MCS died during hospitalization, as compared with 50 (31.3%) of the 160 patients treated with IABP counter-pulsation (p=0.035). MCS was associated with 1.92 (CI=1.10-3.37) times higher 30-day mortality risk and 2.03 (CI=1.17-3.57) times higher 180-day mortality risk. MCS patients (81%) were predominantly treated at 3 of the 8 hospitals (MCS-inclined hospitals) in the region, while IABP use was almost evenly distributed among the MCS-inclined and IABP-inclined hospitals (52.5% versus 47.5%). When comparing MCS-inclined hospitals with IABP-inclined hospitals, patients had significantly higher 180-day mortality (45.3% versus 33.9%, p=0.017), and bleeding rates (15.1% versus 1.3%, p<0.001), with trends toward higher 30-day mortality (41.4% versus 32.6%, p=0.064) and access site injury (4.7% versus 1.3%, p=0.063).
CONCLUSION:
MCS use with a micro-axial left ventricular assist device was associated with reduced survival and higher complication rates in AMICS patients undergoing emergency percutaneous coronary intervention. Before using this device for AMICS, tight selection criteria should be considered to minimize harm and maximize overall benefit.
Acute myocardial infarction with cardiogenic shock continues to be a major concern. Cardiogenic shock (CS) occurs in 10% of patients with ST-elevation acute myocardial infarction (STEMI) and is associated with a 30-day mortality of approximately 40%. With persistently high mortality rates, clinicians use interventions with marginal benefit and some evidence of harm. In this study, we examined the outcomes among AMICS patients treated with mechanical circulatory support (MCS) using a micro-axial left ventricular assist device and intra-aortic balloon counter-pulsation (IABP).
METHODS:
This observational study utilized the Cath PCI Registry v4.4/5.0 from the NCDR, with data augmented by the Xper Information Management System and Sentara EHR. We included patients undergoing acute PCI for STEMI from January 1, 2017, to December 31, 2022, and identified 505 patients with cardiogenic shock across 8 hospitals using registry coding. Primary outcomes were 30 and 180-day mortality, with secondary outcomes including in-hospital complications such as major bleeding, vascular access site injury, new requirement for dialysis, stroke, and sepsis. Statistical analysis was performed with an emphasis of comparing outcomes between 160 patients treated with IABP and 73 patients treated with MCS, as well as outcomes between MCS-inclined and IABP-inclined hospitals.
RESULTS:
Of the 505 AMICS patients, 73 were treated with MCS and 160 with IABP. Baseline characteristics were similar between treatment groups except infarct location. 34 (46.6%) of the 73 patients treated with MCS died during hospitalization, as compared with 50 (31.3%) of the 160 patients treated with IABP counter-pulsation (p=0.035). MCS was associated with 1.92 (CI=1.10-3.37) times higher 30-day mortality risk and 2.03 (CI=1.17-3.57) times higher 180-day mortality risk. MCS patients (81%) were predominantly treated at 3 of the 8 hospitals (MCS-inclined hospitals) in the region, while IABP use was almost evenly distributed among the MCS-inclined and IABP-inclined hospitals (52.5% versus 47.5%). When comparing MCS-inclined hospitals with IABP-inclined hospitals, patients had significantly higher 180-day mortality (45.3% versus 33.9%, p=0.017), and bleeding rates (15.1% versus 1.3%, p<0.001), with trends toward higher 30-day mortality (41.4% versus 32.6%, p=0.064) and access site injury (4.7% versus 1.3%, p=0.063).
CONCLUSION:
MCS use with a micro-axial left ventricular assist device was associated with reduced survival and higher complication rates in AMICS patients undergoing emergency percutaneous coronary intervention. Before using this device for AMICS, tight selection criteria should be considered to minimize harm and maximize overall benefit.