Treatment Intensity for the Management of Cardiogenic Shock: Comparison Between STEMI and Non-STEMI

Shashank S Sinha; Mohit Pahuja; Rachna Kataria; Vanessa Blumer; Jaime Hernandez-Montfort; Manreet Kanwar; A Reshad Garan; Yijing Zhang; Jeffrey A Marbach; Adnan Khalif; Saraschandra Vallabhajosyula; Sandeep Nathan; Jacob Abraham; Borui Li; Katherine L Thayer; Paulina Baca; Fatou Dieng; Neil M Harwani; Michael Y Yin; Anthony J Faugno; Haroon A Faraz; Maya Guglin; Gavin W Hickey; Detlef Wencker; Shelley Hall; Andrew D Schwartzman; Wissam Khalife; Song Li; Claudius Mahr; Ju H Kim; Arvind Bhimaraj; Van-Khue Ton; Esther Vorovich; Daniel Burkhoff; Navin K Kapur

doi:10.1016/j.jacadv.2023.100314

Treatment Intensity for the Management of Cardiogenic Shock: Comparison Between STEMI and Non-STEMI

JACC Adv. 2023 May 26;2(3):100314. doi: 10.1016/j.jacadv.2023.100314. eCollection 2023 May.

Authors

Shashank S Sinha¹, Mohit Pahuja², Rachna Kataria³, Vanessa Blumer⁴, Jaime Hernandez-Montfort⁵, Manreet Kanwar⁶, A Reshad Garan⁷, Yijing Zhang⁸, Jeffrey A Marbach⁷, Adnan Khalif⁶, Saraschandra Vallabhajosyula⁹, Sandeep Nathan¹⁰, Jacob Abraham¹¹, Borui Li⁸, Katherine L Thayer⁸, Paulina Baca⁸, Fatou Dieng⁸, Neil M Harwani⁸, Michael Y Yin⁸, Anthony J Faugno⁸, Haroon A Faraz¹², Maya Guglin¹³, Gavin W Hickey¹⁴, Detlef Wencker⁵, Shelley Hall¹⁵, Andrew D Schwartzman¹⁶, Wissam Khalife¹⁷, Song Li¹⁸, Claudius Mahr¹⁸, Ju H Kim¹⁹, Arvind Bhimaraj¹⁹, Van-Khue Ton²⁰, Esther Vorovich²¹, Daniel Burkhoff²², Navin K Kapur⁸

Affiliations

¹ Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA.
² University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA.
³ Brown University, Lifespan Cardiovascular Center, Providence, Rhode Island, USA.
⁴ Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio, USA.
⁵ Advanced Heart Disease Program, Baylor Scott & White Health, Temple, Texas, USA.
⁶ Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
⁷ Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
⁸ The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA.
⁹ Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
¹⁰ University of Chicago Medicine, Chicago, Illinois, USA.
¹¹ Providence Heart Institute, Center for Cardiovascular Analytics, Research, and Data Science (CARDS), Providence St. Joseph Health, Portland, Oregon, USA.
¹² Hackensack Meridian Health, Hackensack, New Jersey, USA.
¹³ Indiana University Health Advanced Heart and Lung Care, Indianapolis, Indiana, USA.
¹⁴ University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
¹⁵ Baylor Scott & White Advanced Heart Failure Clinic, Dallas, Texas, USA.
¹⁶ Maine Medical Center, Portland, Maine, USA.
¹⁷ University of Texas Medical Branch, Galveston, Texas, USA.
¹⁸ University of Washington Medical Center, Seattle, Washington, USA.
¹⁹ Houston Methodist Research Institute, Houston, Texas, USA.
²⁰ Massachusetts General Hospital, Boston, MA, USA.
²¹ Northwestern Medicine, Chicago, Illinois, USA.
²² Cardiovascular Research Foundation, New York, New York, USA.

Abstract

Background: Cardiogenic shock is a leading cause of mortality in patients with acute myocardial infarction.

Objectives: The authors sought to compare clinical characteristics, hospital trajectory, and drug and device use between patients with ST-segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) and those without (non-ST-segment elevation myocardial infarction complicated by cardiogenic shock [NSTEMI-CS]).

Methods: We analyzed data from 1,110 adult admissions with cardiogenic shock complicating acute myocardial infarction (AMI-CS) across 17 centers within Cardiogenic Shock Working Group. The primary end point was in-hospital mortality.

Results: Our study included 1,110 patients with AMI-CS, of which 731 (65.8%) had STEMI-CS and 379 (34.2%) had NSTEMI-CS. Most patients were male (STEMI-CS: 71.6%, NSTEMI-CS: 66.5%) and White (STEMI-CS: 53.8%, NSTEMI-CS: 64.1%). In-hospital mortality was 41% and was similar among patients with STEMI-CS and NSTEMI-CS (43% vs 39%, P = 0.23). Patients with out-of-hospital cardiac arrest had higher in-hospital mortality in patients with NSTEMI-CS (63% vs 36%, P = 0.006) as compared to patients with STEMI-CS (52% vs 41%, P = 0.16). Similar results were observed for in-hospital cardiac arrest in patients with STEMI-CS (63% vs 33%, P < 0.001) and NSTEMI-CS (60% vs 32%, P < 0.001). Only 27% of patients with STEMI-CS and 12% of NSTEMI-CS received both a drug and temporary mechanical circulatory support device during the first 24 hours, which increased to 78% and 61%, respectively, throughout the course of the hospitalization (P < 0.001 for both).

Conclusions: Despite increasing use of inotropic and vasoactive support and mechanical circulatory support throughout the hospitalization, both patients with STEMI-CS and NSTEMI-CS remain at increased risk for in-hospital mortality. Randomized controls trials are needed to elucidate whether timing and sequence of escalation of support improves outcomes in patients with AMI-CS.

Keywords: acute myocardial infarction; cardiogenic shock; heart failure.