Post-Hospital Outcomes of Patients With Acute Myocardial Infarction With Cardiogenic Shock

Comparison of the prognosis among in-hospital survivors of cardiogenic shock based on etiology: AMI and Non-AMI

BACKGROUND

Current data on post-discharge mortality and rehospitalization is still insufficient among in-hospital survivors of cardiogenic shock (CS), including acute myocardial infarction (AMI) and non-AMI survivors.

METHODS

Patients with CS who survived after hospital discharge were selected from the Taiwan National Health Insurance Research Database. Each patient was followed up at 3-year intervals. Mortality and rehospitalization were analyzed using Kaplan-Meier curves and Cox regression models.

RESULTS

There were 16,582 eligible patients. Of these, 42.4% and 57.6% were AMI-CS and non-AMI-CS survivors, respectively. The overall mortality and rehospitalization rates were considerably high, with reports of 7.0% and 22.1% at 30 days, 24.5% and 58.2% at 1 year, and 38.9% and 73.0% at 3 years, respectively, among in-hospital CS survivors. Cardiovascular (CV) problems caused approximately 40% mortality and 60% rehospitalization. Overall, the non-AMI-CS group had a higher mortality burden than the AMI-CS group owing to older age and a higher prevalence of comorbidities. In multivariable models, the non-AMI-CS group exhibited a lower risk of all-cause mortality (adjusted hazard ratio [aHR] 0.69, 95% confidence interval [CI] 0.60 to 0.78) and CV mortality (aHR 0.65, 95% CI 0.54 to 0.78) compared to the AMI-CS group. However, these risks diminished and even reversed after one year (aHR 1.13, 95% CI 1.03 to 1.25 for all-cause mortality; aHR 1.27, 95% CI 1.09 to 1.49 for CV mortality).This reversal was not observed in all-cause and CV rehospitalization. For rehospitalization, AMI-CS was associated with the risk of CV rehospitalization in the entire observation period (aHR:0.80, 95% CI:0.76-0.84).

CONCLUSIONS

In-hospital AMI-CS survivors had an increased risk of CV rehospitalization and 30-day mortality, whereas those with non-AMI-CS had a greater mortality risk after 1-year follow-up.

Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices

Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.

Optimal Heart Failure Medical Therapy and Mortality in Survivors of Cardiogenic Shock: Insights From the FRENSHOCK Registry

BACKGROUND

The effects of pharmacological therapy on cardiogenic shock (CS) survivors have not been extensively studied. Thus, this study investigated the association between guideline-directed heart failure (HF) medical therapy (GDMT) and one-year survival rate in patients who are post-CS.

METHODS AND RESULTS

FRENSHOCK (French Observatory on the Management of Cardiogenic Shock in 2016) registry was a prospective multicenter observational survey, conducted in metropolitan French intensive care units and intensive cardiac care units. Of 772 patients, 535 patients were enrolled in the present analysis following the exclusion of 217 in-hospital deaths and 20 patients with missing medical records. Patients with triple GDMT (beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists) at discharge (n=112) were likely to have lower left ventricular ejection fraction on admission and at discharge compared with those without triple GDMT (n=423) (22% versus 28%, P<0.001 and 29% versus 37%, P<0.001, respectively). In the overall cohort, the one-year mortality rate was 23%. Triple GDMT prescription was significantly associated with a lower one-year all-cause mortality compared with non-triple GDMT (adjusted hazard ratio 0.44 [95% CI, 0.19-0.80]; P=0.007). Similarly, 2:1 propensity score matching and inverse probability treatment weighting based on the propensity score demonstrated a lower incidence of one-year mortality in the triple GDMT group. As the number of HF drugs increased, a stepwise decrease in mortality was observed (log rank; P<0.001).

CONCLUSIONS

In survivors of CS, the one-year mortality rate was significantly lower in those with triple GDMT. Therefore, this study suggests that intensive HF therapy should be considered in patients following CS.

Need for home care or nursing home admission after myocardial infarction complicated by cardiogenic shock and/or out-of-hospital cardiac arrest

AIMS

Myocardial infarction (MI) with cardiogenic shock (CS) and/or out-of-hospital cardiac arrest (OHCA) are conditions with potential loss of autonomy. In patients with MI, the association between CS and OHCA and need for home care or nursing home admission was examined.

METHODS AND RESULTS

Danish nationwide registries identified patients with MI (2008-19), who prior to the event lived at home without home care and discharged alive. One-year cumulative incidences and hazard ratios (HRs) were reported for home care need or nursing home admission, a composite proxy for disability in activities of daily living (ADL), along with all-cause mortality. The study population consisted of 67 109 patients with MI (by groups: -OHCA/-CS: 63 644; -OHCA/+CS: 1776; +OHCA/-CS: 968; and +OHCA/+CS: 721). The 1-year cumulative incidences of home care/nursing home were 7.1% for patients who survived to discharge with -OHCA/-CS, 20.9% for -OHCA/+CS, 5.4% for +OHCA/-CS, and 8.2% for those with +OHCA/+CS. The composite outcome was driven by home care. With the -OHCA/-CS as reference, the adjusted HRs for home care/nursing home were 2.86 (95% CI: 2.57-3.19) for patients with -OHCA/+CS; 1.31 (95% CI: 1.00-1.73) for + OHCA/-CS; and 2.18 (95% CI: 1.68-2.82) for those with +OHCA/+CS. The 1-year cumulative mortality were 5.1% for patients with -OHCA/-CS, 9.8% for -OHCA/+CS, 3.0% for +OHCA/-CS, and 3.4% for those with +OHCA/+CS.

CONCLUSION

In patients discharged alive after a MI, CS, and to a lesser degree OHCA were associated with impaired ADL with a two-fold higher 1-year incidence of home care or nursing home admission compared with MI patients without CS or OHCA.

Outcomes and Institutional Variation in Arterial Access Among Patients With AMI and Cardiogenic Shock Undergoing PCI

BACKGROUND

Contemporary data comparing the outcomes of transradial access (TRA) vs transfemoral access (TFA) among patients presenting with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI) are limited.

OBJECTIVES

This study examines in-hospital outcomes and institutional variation among patients with AMI-CS undergoing TRA-PCI vs TFA-PCI.

METHODS

Patients admitted with AMI-CS from the NCDR CathPCI registry between April 2018 and June 2021 were included. Multivariable logistic regression and inverse probability weighting models were used to assess the association between access site and in-hospital outcomes. A falsification analysis using non-access site-related bleeding was performed.

RESULTS

Among 35,944 patients with AMI-CS undergoing PCI, 25.6% were performed with TRA. The proportion of TRA-PCI increased over the study period (22.0% in the second quarter of 2018 vs 29.1% in the second quarter of 2021; P-trend <0.001). Significant institutional-level variability in the use of TRA-PCI was also observed: 20.9% of all sites using TRA in <2% of PCIs (low utilization) vs 1.9% of all sites using TRA in >80% of PCIs (high utilization). Patients undergoing TRA-PCI had a significantly lower adjusted incidence of major bleeding (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.67-0.76), mortality (OR: 0.73; 95% CI: 0.69-0.78), vascular complications (OR: 0.67; 95% CI: 0.54-0.84), and new dialysis (OR: 0.86; 95% CI: 0.77-0.97). There was no difference in non-access site related bleeding (OR: 0.93; 95% CI: 0.84-1.03). Sensitivity analyses revealed similar benefit with TRA-PCI among patients without arterial cross-over. There were no significant interactions observed between TRA-PCI with mechanical circulatory support and in-hospital outcomes.

CONCLUSIONS

In this large nationwide contemporary analysis of patients with AMI-CS, about quarter of PCIs were performed via TRA with wide variability across US institutions. TRA-PCI was associated with significantly lower incidence of in-hospital major bleeding, mortality, vascular complications, and new dialysis. This benefit was observed irrespective of mechanical circulatory support use.

Outcomes of surgical Impella placement in acute cardiogenic shock

Introduction

Although a role for percutaneous Impella devices has been established, there is a paucity of data regarding the utility and outcomes of larger surgically implanted Impella devices.

Methods

We conducted a retrospective review of all surgical Impella implants at our institution. All Impella 5.0 and Impella 5.5 devices were included. The primary outcome was survival. Secondary outcomes included hemodynamic and end-organ perfusion as well as commonly encountered surgical complications.

Results

From 2012 to 2022, 90 surgical Impella devices were implanted. The median age was 63 [53-70] years, the mean creatinine was 2.07 ± 1.22 mg/dL, and the average lactate level was 3.32 ± 2.90 mmol/L. Prior to implantation, 47 patients (52%) were supported with vasoactive agents, while 43 (48%) were also supported with another device. The most common etiology of shock was acute on chronic heart failure (50, 56%), followed by acute myocardial infarction (22, 24%), and postcardiotomy (17, 19%). Overall, 69 patients (77%) survived to device removal, and 57 (65%) survived to hospital discharge. One-year survival was 54%. Neither etiology of heart failure nor device strategy was associated with 30-day or 1-year survival. On multivariable modeling, the number of vasoactive medications prior to device implantation was strongly associated with 30-day mortality (hazard ratio 1.94 [1.27-2.96], P < 0.01). Surgical Impella placement was associated with a significant decreased need for vasoactive infusions (P < 0.01) and decreased acidosis (P = 0.01).

Conclusions

Surgical Impella support for patients in acute cardiogenic shock is associated with lower vasoactive medication use, improved hemodynamics, increased end-organ perfusion, and acceptable morbidity and mortality.

Impella Versus VA-ECMO for Patients with Cardiogenic Shock: Comprehensive Systematic Literature Review and Meta-Analyses

Impella and VA-ECMO are two possible therapeutic courses for the treatment of patients with cardiogenic shock (CS). The study aims to perform a systematic literature review and meta-analyses of a comprehensive set of clinical and socio-economic outcomes observed when using Impella or VA-ECMO with patients under CS. A systematic literature review was performed in Medline, and Web of Science databases on 21 February 2022. Nonoverlapping studies with adult patients supported for CS with Impella or VA-ECMO were searched. Study designs including RCTs, observational studies, and economic evaluations were considered. Data on patient characteristics, type of support, and outcomes were extracted. Additionally, meta-analyses were performed on the most relevant and recurring outcomes, and results shown using forest plots. A total of 102 studies were included, 57% on Impella, 43% on VA-ECMO. The most common outcomes investigated were mortality/survival, duration of support, and bleeding. Ischemic stroke was lower in patients treated with Impella compared to the VA-ECMO population, with statistically significant difference. Socio-economic outcomes including quality of life or resource use were not reported in any study. The study highlighted areas where further data collection is needed to clarify the value of complex, new technologies in the treatment of CS that will enable comparative assessments focusing both on the health impact on patient outcomes and on the financial burden for government budgets. Future studies need to fill the gap to comply with recent regulatory updates at the European and national levels.

Contemporary Management of Cardiogenic Shock Complicating Acute Myocardial Infarction

Despite an improvement in pharmacological therapies and mechanical reperfusion, the outcome of patients with acute myocardial infarction (AMI) is still suboptimal, especially in patients with cardiogenic shock (CS). The incidence of CS accounts for 3-15% of AMI cases, with mortality rates of 40% to 50%. In contrast to a large number of trials conducted in patients with AMI without CS, there is limited evidence-based scientific knowledge in the CS setting. Therefore, recommendations and actual treatments are often based on registry data. Similarly, knowledge of the available options in terms of temporary mechanical circulatory support (MCS) devices is not equally widespread, leading to an underutilisation or even overutilisation in different regions/countries of these treatment options and nonuniformity in the management of CS. The aim of this article is to provide a critical overview of the available literature on the management of CS as a complication of AMI, summarising the most recent evidence on revascularisation strategies, pharmacological treatments and MCS use.

Contemporary Data on the Status and Medical Management of Acute Heart Failure

PURPOSE OF REVIEW

Acute heart failure (AHF) is among the leading causes for unplanned hospital admission. Despite advancements in the management of chronic heart failure, the prognosis of AHF remains poor with high in-hospital mortality and increased rates of unfavorable post-discharge outcomes. With this review, we aim to summarize current data on AHF epidemiology, focus on the different patient profiles and classifications, and discuss management, including novel therapeutic options in this area.

RECENT FINDINGS

There is significant heterogeneity among patients admitted for AHF in their baseline characteristics, heart failure (HF) aetiology and precipitating factors leading to decompensation. A novel classification scheme based on four distinct clinical scenarios has been included in the most recent ESC guidelines, in an effort to better risk stratify patients and guide treatment. Intravenous diuretics, vasodilators, and inotropes remain the cornerstone of management in the acute phase, and expansion of use of mechanical circulatory support has been noted in recent years. Meanwhile, many treatments that have proved their value in chronic heart failure demonstrate promising results in the setting of AHF and research in this field is currently ongoing. Acute heart failure remains a major health challenge with high in-hospital mortality and unfavorable post-discharge outcomes. Admission for acute HF represents a window of opportunity for patients to initiate appropriate treatment as soon as possible after stabilization. Future studies are needed to elucidate which patients will benefit the most by available therapies and define the optimal timing for treatment implementation.

Contemporary Management of Concomitant Cardiac Arrest and Cardiogenic Shock Complicating Myocardial Infarction

Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.

The Battle against Cardiogenic Shock

Cardiogenic shock (CS) is a life-threatening condition characterized by hypoperfusion and hypoxia caused by low cardiac output [...].

Impact of Pre-Existing History of Heart Failure on Patient Profile, Therapeutic Management, and Prognosis in Cardiogenic Shock: Insights from the FRENSHOCK Registry

There is a large heterogeneity among patients presenting with cardiogenic shock (CS). It is crucial to better apprehend this heterogeneity in order to adapt treatments and improve prognoses in these severe patients. Notably, the presence (or absence) of a pre-existing history of chronic heart failure (CHF) at time of CS onset may be a significant part of this heterogeneity, and data focusing on this aspect are lacking. We aimed to compare CS patients with new-onset HF to those with worsening CHF in the multicenter FRENSHOCK registry. Altogether, 772 CS patients were prospectively included: 433 with a previous history of CHF and 339 without. Worsening CHF patients were older (68 +/− 13.4 vs. 62.7 +/− 16.2, p < 0.001) and had a greater burden of extra-cardiac comorbidities. At admission, acute myocardial infarction was predominantly observed in the new-onset HF group (49.9% vs. 25.6%, p < 0.001). When focusing on hemodynamic parameters, worsening CHF patients showed more congestion and higher ventricular filling pressures. Worsening CHF patients experienced higher in-hospital all-cause mortality (31.3% vs. 24.2%, p = 0.029). Our results emphasize the great heterogeneity of the patients presenting with CS. Worsening CHF patients had higher risk profiles, and this translated to a 30% increase in in-hospital all-cause mortality. The heterogeneity of this population prompts us to better determine the phenotype of CS patients to adapt their management.

Effect Analysis of Nursing Method Based on Stratified Emergency Knowledge in Emergency Myocardial Infarction

First aid is to give immediate first aid to patients who have suffered accidental injuries or sudden diseases before the emergency medical personnel arrive at the scene or are sent to the hospital for treatment; myocardial infarction is a severe and emergency of coronary heart disease. It is often because of coronary atherosclerosis, plaque rupture, bleeding, or thrombosis, which leads to the acute and complete occlusion of the coronary arteries and acute necrosis of the myocardium. This article aims to investigate the effectiveness of a stratified emergency care team assisted by multidisciplinary first aid knowledge in acute myocardial infarction first aid, hoping to reduce the probability of acute myocardial infarction through first aid and nursing care. Business process reengineering is a management idea that reached its heyday in the 1990s and is usually defined as achieving workflow and productivity through the reorganization and optimization of corporate strategies, value-added operational processes, and the systems, policies, organizations, and structures that support them. This article first outlines the concepts and steps of medical image registration, analyzes the characteristics of current medical image registration methods, and uses the two most commonly used medical registration methods today; in this study, the BPR theory was used to construct the AMI emergency care process in the hospital, which effectively reduced the emergency delay time of AMI patients, improved the patient's emergency response, and increased the efficiency of emergency nurses' rescue work. The experimental results in this paper show that the sensitivities of the first four groups of ST↑III > II, ST ↓ aVL > I, STV3 ↓ /STIII↑≤1.2, STI ↓ ≥0.05 mV are 82.1%, 80%, 75.3%, and 60.3%, respectively. Their sensitivities are relatively close, both are greater than 50%; among them, ST↑III > II has the highest sensitivity, which is 80%. In terms of specificity, ST↑III > II, ST ↓ aVL > I, STV3 ↓ /STIII↑≤1.2, and STI ↓ ≥0.05 mV were 82.1%, 89.2%, 82.7%, and 65.2%, respectively. ST ↓ ≥0.05 mV has the lowest specificity, and ST ↓ aVL > I has the highest specificity.

Establishing a Cardiac ICU Recovery Clinic: Characterizing a Model for Continuity of Cardiac Critical Care

BACKGROUND

Care in the cardiovascular intensive care unit (CICU) has become increasingly intricate due to a temporal rise in noncardiac diagnoses and overall clinical complexity with high risk for short-term rehospitalization and mortality. Survivors of critical illness are often faced with debility and limitations extending beyond the index hospitalization. Comprehensive ICU recovery programs have demonstrated some efficacy but have primarily targeted survivors of acute respiratory distress syndrome or sepsis. The efficacy of dedicated ICU recovery programs on the CICU population is not defined.

METHODS

We aim to describe the design and initial experience of a novel CICU-recovery clinic (CICURC). The primary outcome was death or rehospitalization in the first 30 days following hospital discharge. Self-reported outcome measures were performed to assess symptom burden and independence in activities of daily living.

RESULTS

Using standardized criteria, 41 patients were referred to CICURC of which 78.1% established care and were followed for a median of 88 (56-122) days. On intake, patients reported a high burden of heart failure symptoms (KCCQ overall summary score 29.8 [18.0-47.5]), and nearly half (46.4%) were dependent on caretakers for activities of daily living. Thirty days postdischarge, no deaths were observed and the rate of rehospitalization for any cause was 12.2%.

CONCLUSIONS

CICU survivors are faced with significant residual symptom burden, dependence upon caretakers, and impairments in mental health. Dedicated CICURCs may help prioritize treatment of ICU related illness, reduce symptom burden, and improve outcomes. Interventions delivered in ICU recovery clinic for patients surviving the CICU warrant further investigation.

The Multicenter Collaborative to Enhance Biologic Understanding, Quality, and Outcomes in Cardiogenic Shock (VANQUISH Shock): Rationale and Design

BACKGROUND

Despite efforts to advance therapies in cardiogenic shock (CS), outcomes remain poor. This is likely due to several factors, including major gaps in our understanding of the pathophysiology, phenotyping of patients, and challenges with conducting adequately powered clinical studies. An unmet need exists for a comprehensive multicentre "all-comers" prospective registry to facilitate characterising contemporary presentation, treatment (in a device-agnostic fashion), and short- and intermediate-term outcomes and quality of life (QOL) of CS patients.

METHODS

The Multicenter Collaborative to Enhance Biological Understanding, Quality and Outcomes in Cardiogenic Shock (VANQUISH Shock) registry is a prospective observational registry that will study unrestricted adult patients with a primary diagnosis of CS at 4 North American centres with multidisciplinary shock programs. Both acute myocardial infarction (AMI-CS) and acute heart failure (HF-CS) etiologies will be included, and the registry will be device agnostic and widely inclusive. The primary end point will be survival at 30 days after hospital discharge. Secondary outcomes will include in-hospital adverse events and survival to 6 and 12 months. Patients will also undergo neurologic and health-related QOL assessments with the Cerebral Performance Category (CPC) and Short-Form 36 (SF-36) health survey tools before discharge and during follow-up. Serial biospecimens will facilitate biomarker studies.

CONCLUSIONS

The VANQUISH Shock registry provides a unique opportunity to study the pathophysiology, contemporary management, clinical course, and outcomes of CS. By capturing detailed and high-quality longitudinal data, the registry will address existing knowledge gaps and serve as a springboard for future mechanistic clinical studies to advance the field.

Ability of the LACE Index to Predict 30-Day Readmissions in Patients with Acute Myocardial Infarction

Aims: This study aimed to utilize the existing LACE index (length of stay, acuity of admission, comorbidity index and emergency room visit in the past six months) to predict the risk of 30-day readmission and to find the associated factors in patients with AMI. Methods: This was a retrospective study and LACE index scores were calculated for patients admitted with AMI between 2015 and 2019. Data were utilized from the hospital’s electronic medical record. Multivariate logistic regression was performed to find the association between covariates and 30-day readmission. The risk prediction ability of the LACE index for 30-day readmission was analyzed by receiver operating characteristic curves with the C statistic. Results: A total of 205 (5.7%) patients were readmitted within 30 days. The odds ratio of older age group (OR = 1.78, 95% CI: 1.54–2.05), admission via emergency ward (OR = 1.45; 95% CI: 1.42–1.54) and LACE score ≥10 (OR = 2.71; 95% CI: 1.03–4.37) were highly associated with 30-day readmissions and statistically significant. The receiver operating characteristic curve C statistic of the LACE index for AMI patients was 0.78 (95% CI: 0.75–0.80) and showed favorable discrimination in the prediction of 30-day readmission. Conclusion: The LACE index showed a good discrimination to predict the risk of 30-day readmission for hospitalized patients with AMI. Further study would be recommended to focus on additional factors that can be used to predict the risk of 30-day readmission; this should be considered to improve the model performance of the LACE index for other acute conditions by using the national-based administrative data.

When to Achieve Complete Revascularization in Infarct-Related Cardiogenic Shock

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encountered in patients with multivessel coronary artery disease (CAD). Despite prompt revascularization, in particular, percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for patients with CS related to AMI remains unacceptably high. Differently form a hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested for AMI–CS patients, based on the results of recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have emerged as a key therapeutic option in CS, especially in the case of their early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of the current evidence on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of different types of MCS devices and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

Sex Differences in Management and Outcomes of Acute Myocardial Infarction Patients Presenting With Cardiogenic Shock

OBJECTIVES

The aim of this study was to examine the sex differences in the risk profile, management, and outcomes among patients presenting with acute myocardial infarction cardiogenic shock (AMI-CS).

BACKGROUND

Contemporary clinical data regarding sex differences in the management and outcomes of AMI patients presenting with CS are scarce.

METHODS

Patients admitted with AMI-CS from the National Cardiovascular Data Registry Chest Pain-MI registry between October 2008 to December 2017 were included. Sex differences in baseline characteristics, in-hospital management, and outcomes were compared. Patients ≥65 years of age with available linkage data to Medicare claims were included in the analysis of 1-year outcomes. Multivariable logistic regression and Cox proportional hazards models adjusting for patient and hospital-related covariates were used to estimate sex-specific differences in in-hospital and 1-year outcomes, respectively.

RESULTS

Among 17,195 patients presenting with AMI-CS, 37.3% were women. Women were older, had a higher prevalence of comorbidities, and had worse renal function at presentation. Women were less likely to receive guideline-directed medical therapies within 24 hours and at discharge, undergo diagnostic angiography (85.0% vs 91.1%), or receive mechanical circulatory support (25.4% vs 33.8%). Women had higher risks of in-hospital mortality (adjusted OR: 1.10; 95% CI: 1.02-1.19) and major bleeding (adjusted OR: 1.23; 95% CI: 1.12-1.34). For patients ≥65 years of age, women did not have a higher risk of all-cause mortality (adjusted HR: 0.98; 95% CI: 0.88-1.09) and mortality or heart failure hospitalization (adjusted HR: 1.01; 95% CI: 0.91-1.12) at 1 year compared with men.

CONCLUSIONS

In this large nationwide analysis of patients with AMI-CS, women were less likely to receive guideline recommended care, including revascularization, and had worse in-hospital outcomes than men. At 1 year, there were no sex differences in the risk of mortality. Efforts are needed to address sex disparities in the initial care of AMI-CS patients.

Prognostic implications of pulmonary artery catheter monitoring in patients with cardiogenic shock: A systematic review and meta-analysis of observational studies

PURPOSE

To investigate the impact of pulmonary artery catheter (PAC) monitoring on survival of cardiogenic shock(CS), in the light of the controversies in available evidence.

MATERIALS AND METHODS

MEDLINE, EMBASE, Cochrane library and Web of Science were systematically screened to identify most relevant studies on patients with CS comparing PAC use to non-use during hospital stay. Short-term mortality was the primary endpoint and the use of Mechanical Circulatory Support (MCS) devices was the secondary one.

RESULTS

Six observational studies including 1,166,762 patients were selected. The most frequent etiology of CS was post-myocardial infarction (75% [95% CI 55-89%] in PAC-group and 81%[95% CI 47-95%] in non-PAC group). Overall, PAC was used in 33%(95% CI 24-44%) of cases. Pooling data adjusted for confounders, a significant association between the PAC-group and a reduction in short-term mortality emerged when compared to the non-PAC group (36%[95% CI 27-45%] vs 47%[95% CI 35-59%];AdjustedOR 0.71, 95% CI 0.59-0.87, p < 0.01). MCS use was significantly higher in PAC vs non-PAC group (59% [95% CI 54-65%]) vs 48% [95% CI 43-53%]);OR 1.60 [95% CI 1.27-2.02, p < 0.01]).

CONCLUSIONS

PAC was associated with lower incidence of short-term mortality in CS pooling adjusted observational studies. Prospective studies are needed to confirm our hypothesis and better clarify the mechanisms of this potential prognostic benefit.

Atrial Fibrillation and Coronary Artery Disease: A Long-Term Perspective on the Need for Combined Antithrombotic Therapy

BACKGROUND

Older adults with atrial fibrillation (AF) are often treated with the shortest possible duration of antiplatelet/anticoagulant therapy after myocardial infarction (MI) or percutaneous coronary intervention (PCI) due to concern for bleeding. However, the risk of recurrent MI or PCI prompting antiplatelet therapy extension is unknown in this population.

METHODS

Using the National Cardiovascular Data Registry linked to Medicare claims, we described the cumulative incidence of recurrent MI or PCI over a median of 7-year follow-up for patients ≥65 years old with AF discharged alive after acute MI between 2008 and 2017. We used pharmacy fill data to describe the proportion of patients filling prescriptions for both oral anticoagulants and P2Y₁₂ inhibitors for ≥50% of the indicated duration after MI or PCI.

RESULTS

Of 187 622 older patients discharged alive after MI, 50 539 (26.9%) had AF. Over a median of 7-year follow-up in patients with AF, the cumulative incidence was 14.5% for recurrent MI, 12.1% for PCI, 7.9% for stroke, and 9.5% for bleeding hospitalization. Among 7998 patients with AF and recurrent MI or PCI, 1668 (20.9%) had >1 MI or PCI during follow-up. Assuming each MI or PCI should be followed by 6 months of P2Y₁₂ inhibitor therapy, patients with AF who had a recurrent MI/PCI had a median estimated indication for antiplatelet/anticoagulant treatment of 287 days (194, 358), but filled both P2Y₁₂ inhibitor and oral anticoagulant for a median of 0 days (0, 21). In this cohort, 12.2% of patients filled prescriptions for both a P2Y₁₂ inhibitor and oral anticoagulant for ≥50% of the indicated duration.

CONCLUSIONS

Older adults with AF and MI have high incidences of downstream recurrent MI or PCI requiring extended antiplatelet/anticoagulant therapy durations, yet many appear to be under-treated. These results highlight the need for better thrombosis prevention strategies in this group of patients.

Efficacy and safety of Impella 5.0 in cardiogenic shock: an updated systematic review

Aim: The impact on safety and efficacy outcomes of Impella 5.0 in cardiogenic shock (CS) has not been systematically assessed. Materials & methods: We conducted a systematic review of the literature (PROSPERO protocol: CRD42020164680) to critically appraise available evidence on Impella 5.0 comparative safety, efficacy and effectiveness. Results: Of 244 retrieved citations, 17 original articles met the a priori defined inclusion criteria. All included studies had a retrospective study design and, overall, reported on, respectively, 52 and 67 different safety and efficacy/effectiveness outcomes. Thirty-day survival rates ranged from 40 to 94%, myocardial recovery from 18 to 93%. Conclusion: Impella 5.0 provides a full cardiac support, it is associated with a lower rate of vascular complications, it represents a valuable bridge-to-decision and allows for resolution of intercurrent clinical conditions. As available data suggest Impella 5.0 good performance in CS of various etiologies, more solid evidence will come from much-needed large-scale all-comer registries and prospective multicenter randomized trials.

How Would the Authors Treat Their Own Temporary Left Ventricular Failure With Mechanical Circulatory Support?

In the last 20 years, mechanical circulatory supports (MCS) have overturned completely the outcomes and the clinical recovery of patients with isolated acute left ventricle failure (iALVF). This usually occurs more frequently than right-sided heart failure or biventricular dysfunction, and it mainly is caused by acute myocardial infarction. The primary role of MCS is to restore the tissue metabolism to preserve the vital organs' function but, on the other hand, they also have to relieve the workload stress on the heart. In this way, they allow not only the heart to recover from the acute event, but MCS also can stabilize the patient toward cardiac transplantation. The short-term MCS devices currently used in clinical practice are the intraaortic balloon pump, the Impella (Abiomed, Danvers, MA), and venoarterial extracorporeal membrane oxygenation (VA-ECMO), but the choice of the right and tailored device for each patient, as well as the timing to use it, is actually one of the most debated topics of MCS management.

Predicting 1-Year Mortality on Admission Using the Mayo Cardiac Intensive Care Unit Admission Risk Score

OBJECTIVE

To determine whether the Mayo Cardiac Intensive Care Unit (CICU) Admission Risk Score (M-CARS) accurately predicts 1-year mortality.

METHODS

We retrospectively reviewed adult CICU patients admitted from January 1, 2007, through April 30, 2018, and calculated M-CARS using admission data. We examined the association between admission M-CARS, as continuous and categorical variables, and 1-year mortality.

RESULTS

This study included 12,428 unique patients with a mean age of 67.6±15.2 years (4686 [37.7%] female). A total of 2839 patients (22.8%) died within 1 year of admission, including 1149 (9.2%) hospital deaths and 1690 (15.0%) of the 11,279 hospital survivors. The 1-year survival decreased incrementally as a function of increasing M-CARS (P<.001), and all components of M-CARS were significant predictors of 1-year mortality (P<.001). The 1-year survival among hospital survivors decreased incrementally as a function of increasing M-CARS for scores below 3 (all P<.001); however, there was no further decrease in 1-year survival for hospital survivors with M-CARS of 3 or more (P=.99). The M-CARS components associated with 1-year mortality among hospital survivors included blood urea nitrogen, red blood cell distribution width, Braden skin score, and respiratory failure (all P<.001).

CONCLUSION

M-CARS predicted 1-year mortality among CICU admissions, with a plateau effect at high M-CARS of 3 or more for hospital survivors. Significant added predictors of 1-year mortality among hospital survivors included markers of frailty and chronic illness.

Racial, Ethnic, and Sex Disparities in Patients With STEMI and Cardiogenic Shock

OBJECTIVES

The aim of this study was to evaluate the combined impact of race, ethnicity, and sex on in-hospital outcomes using data from the National Inpatient Sample.

BACKGROUND

Cardiogenic shock (CS) is a major cause of mortality following ST-segment elevation myocardial infarction (STEMI). Early revascularization reduces mortality in such patients. Mechanical circulatory support (MCS) devices are increasingly used to hemodynamically support patients during revascularization. Little is known about racial, ethnic, and sex disparities in patients with STEMI and CS.

METHODS

The National Inpatient Sample was queried from January 2006 to September 2015 for hospitalizations with STEMI and CS. The associations between sex, race, ethnicity, and outcomes were examined using complex-samples multivariate logistic or generalized linear model regressions.

RESULTS

Of 159,339 patients with STEMI and CS, 57,839 (36.3%) were women. In-hospital mortality was higher for all women (range 40% to 45.4%) compared with men (range 30.4% to 34.7%). Women (adjusted odds ratio [aOR]: 1.11; 95% confidence interval [CI]: 1.06 to 1.16; p < 0.001) as well as Black (aOR: 1.18; 95% CI: 1.04 to 1.34; p = 0.011) and Hispanic (aOR: 1.19; 95% CI: 1.06 to 1.33; p = 0.003) men had higher odds of in-hospital mortality compared with White men, with Hispanic women having the highest odds of in-hospital mortality (aOR: 1.46; 95% CI: 1.26 to 1.70; p < 0.001). Women were older (age: 69.8 years vs. 63.2 years), had more comorbidities, and underwent fewer invasive cardiac procedures, including revascularization, right heart catheterization, and MCS.

CONCLUSIONS

There are significant racial, ethnic, and sex differences in procedural utilization and clinical outcomes in patients with STEMI and CS. Women are less likely to undergo invasive cardiac procedures, including revascularization and MCS. Women as well as Black and Hispanic patients have a higher likelihood of death compared with White men.

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Patients With Non-ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

OBJECTIVES

The aim of this study was to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD) and cardiogenic shock.

BACKGROUND

The clinical benefits of complete revascularization in patients with NSTEMI, MVD, and cardiogenic shock remain uncertain.

METHODS

Among 25,324 patients included in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to March 2018, the rates of in-hospital procedural outcomes were compared between those undergoing multivessel PCI and those undergoing culprit vessel-only PCI after 1:1 propensity score matching. Among patients aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis.

RESULTS

Multivessel PCI was performed in 9,791 patients (38.7%), which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend <0.001). After 1:1 propensity matching (n = 7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI]: 2.0% to 5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%; p < 0.001; odds ratio [OR]: 0.85; 95% CI: 0.80 to 0.91), but a higher risk for bleeding (13.2% vs. 10.8%; p < 0.001; OR: 1.26; 95% CI: 1.15 to 1.40) and new requirement for dialysis (5.7% vs. 4.6%; p = 0.001; OR: 1.26; 95% CI: 1.10 to 1.46). Among those surviving to discharge, all-cause mortality was similar through 7 years (conditional hazard ratio: 0.95; 95% CI: 0.87 to 1.03; p = 0.20).

CONCLUSIONS

Nearly 40% of patients with NSTEMI with MVD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater peri-procedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.

Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association

Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.

Use of Post-Acute Care Services and Readmissions After Acute Myocardial Infarction Complicated by Cardiac Arrest and Cardiogenic Shock

OBJECTIVE

To evaluate post-acute care utilization and readmissions after cardiac arrest (CA) and cardiogenic shock (CS) complicating acute myocardial infarction (AMI).

METHODS

With use of an administrative claims database, AMI patients from January 1, 2010, to May 31, 2018, were stratified into CA+CS, CA only, CS only, and AMI alone. Outcomes included 90-day post-acute care (inpatient rehabilitation or skilled nursing facility) utilization and 1-year emergency department visits and readmissions.

RESULTS

Of 163,071 AMI patients, CA+CS, CA only, and CS only were noted in 3965 (2.4%), 8221 (5.0%), and 6559 (4.0%), respectively. In-hospital mortality was noted in 10,686 (6.6%) patients: CA+CS, 1935 (48.8%); CA only, 2948 (35.9%); CS only, 1578 (24.1%); and AMI alone, 4225 (2.9%) (P<.001). Among survivors, post-acute care services were used in 67,799 (44.5%), with higher use in the CS+CA cohort (1310 [64.6%]; hazard ratio [HR], 1.19; 95% CI, 1.06 to 1.33; P=.003) and CA cohort (2738 [51.9%]; HR, 1.27; 95% CI, 1.20 to 1.35; P<.001) but not in the CS cohort (3048 [61.2%]; HR, 1.03; 95% CI, 0.97 to 1.11; P=.35) compared with the AMI cohort (60,703 [43.3%]). Compared with the AMI cohort (48,990 [35.0%]), patients with CS only (2,085 [41.9%]; HR, 1.16; 95% CI, 1.10 to 1.22; P<.001) but not those with CA+CS (724 [35.7%]; HR, 1.07; 95% CI, 0.98 to 1.17; P=.14) had higher rates of readmissions (P=.03). Readmissions were lower in those with CA (1,590 [30.2%]; HR, 0.94; 95% CI, 0.89 to 0.99). Repeated AMI, coronary artery disease, and heart failure were the most common readmission reasons. There were no differences for emergency department visits.

CONCLUSION

CA is associated with increased post-acute care use, whereas CS is associated with increased readmission risk in AMI survivors.

Early intra-aortic balloon pump in acute decompensated heart failure complicated by cardiogenic shock: Rationale and design of the randomized Altshock-2 trial

BACKGROUND

Cardiogenic shock (CS) is a systemic disorder associated with dismal short-term prognosis. Given its time-dependent nature, mechanical circulatory support may improve survival. Intra-aortic balloon pump (IABP) had gained widespread use because of the easiness to implant and the low rate of complications; however, a randomized trial failed to demonstrate benefit on mortality in the setting of acute myocardial infarction. Acute decompensated heart failure with cardiogenic shock (ADHF-CS) represents a growing resource-intensive scenario with scant data and indications on the best management. However, a few data suggest a potential benefit of IABP in this setting. We present the design of a study aimed at addressing this research gap.

METHODS AND DESIGN

The Altshock-2 trial is a prospective, randomized, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients with ADHF-CS will be randomized to early IABP implantation or to vasoactive treatments. The primary end point will be 60 days patients' survival or successful bridge to heart replacement therapy. The key secondary end point will be 60-day overall survival; 60-day need for renal replacement therapy; in-hospital maximum inotropic score, maximum duration of inotropic/vasopressor therapy, and maximum sequential organ failure assessment score. Safety end points will be in-hospital occurrence of bleeding events (Bleeding Academic Research Consortium >3), vascular access complications and systemic (noncerebral) embolism. The sample size for the study is 200 patients.

IMPLICATIONS

The Altshock-2 trial will provide evidence on whether IABP should be implanted early in ADHF-CS patients to improve their clinical outcomes.

Veno-arterial extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock: rationale and design of the randomised, multicentre, open-label EURO SHOCK trial

AIMS

Cardiogenic shock (CGS) occurs in 6-10% of patients with acute coronary syndromes (ACS). Mortality has fallen over time from 80% to approximately 50% consequent on acute revascularisation but has plateaued since the 1990s. Once established, patients with CGS develop adverse compensatory mechanisms that contribute to the downward spiral towards death, which becomes difficult to reverse. We aimed to test in a robust, prospective, randomised controlled trial whether early support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides clinical benefit by improving mortality and morbidity.

METHODS AND RESULTS

The EURO SHOCK trial will test the benefit or otherwise of mechanical cardiac support using VA-ECMO, initiated early after acute percutaneous coronary intervention (PCI) for CGS. The trial sets out to randomise 428 patients with CGS complicating ACS, following primary PCI (P-PCI), to either very early ECMO plus standard pharmacotherapy, or standard pharmacotherapy alone. It will be conducted in 39 European centres. The primary endpoint is 30-day all-cause mortality with key secondary endpoints: 1) 12-month all-cause mortality or admission for heart failure, 2) 12-month all-cause mortality, 3) 12-month admission for heart failure. Cost-effectiveness analysis (including quality of life measures) will be embedded. Mechanistic and hypothesis-generating substudies will be undertaken.

CONCLUSIONS

The EURO SHOCK trial will determine whether early initiation of VA-ECMO in patients presenting with ACS-CGS persisting after PCI improves mortality and morbidity.

Outcomes after readmission at the index or nonindex hospital following acute myocardial infarction complicated by cardiogenic shock

Little is known about the prevalence and outcomes of readmission to nonindex hospitals after an admission for acute myocardial infarction complicated by cardiogenic shock (AMI‐CS). We aimed to determine the rate of nonindex readmissions following AMI‐CS and to evaluate its association with clinical factors, hospitalization cost, length of stay (LOS), and in‐hospital mortality rates.

Hypothesis

Nonindex readmission may lead to worse in‐hospital outcomes.

Methods

We reviewed the data of inpatients with AMI‐CS between 2010 and 2017 using the National Readmission Database. The survey analytical methods recommended by the Healthcare Cost and Utilization Project were used for national estimates. Multiple regression models were used to evaluate the predictors of nonindex readmission, and its association with hospitalization cost, LOS, and in‐hospital mortality rates.

Results

Of 238 349 patients with AMI‐CS, 28028 (11.76%) had an unplanned readmission within 30 days. Of these patients, 7423 (26.48%) were readmitted to nonindex hospitals. Compared with index readmission, nonindex readmission was associated with higher hospitalization costs (p < .0001), longer LOS (p < .0001), and increased in‐hospital mortality rates (p = .0016). Patients who had a history of percutaneous coronary intervention, received intubation/mechanical ventilation, or left against medical advice during the initial admission had greater odds of a nonindex readmission.

Conclusions

Over one‐fourth of readmissions following AMI‐CS were to nonindex hospitals. These admissions were associated with higher hospitalization costs, longer LOS, and higher in‐hospital mortality rates. Further studies are needed to evaluate whether a continuity of care plan in the acute hospital setting can improve outcomes after AMI‐CS.

Percutaneous coronary intervention assisted by invasive mechanical ventilation and intra-aortic balloon pump for acute myocardial infarction with cardiogenic shock: Retrospective cohort study and meta-analyses

There is little evidence to recommend the optimal invasive mechanical ventilation (IMV) modes and ideal positive end-expiratory pressure stress levels for acute myocardial infarction-cardiogenic shock (AMI-CS) patients. The aim of this study was to compare the mortality outcome in patients with AMI-CS who were treated with percutaneous coronary intervention (PCI) assisted by intra-aortic balloon pump (IABP) + IMV with historical controls. From January 1, 2016 to June 1, 2017, 60 patients were retrospectively enrolled at Tianjin Chest Hospital. Out of these, 88.3% of patients achieved thrombolysis in myocardial infarction (TIMI) flow 3 after PCI. The all-cause mortality rate in-hospital and at 1 year was 25% (95% CI: 0.14–0.36) and 33.9% (0.22–0.46), respectively. A systematic review followed by meta-analysis was performed with four historical studies of patients treated by PCI + IMV with partial IABP, which found an in-hospital mortality rate of 66.0% (95% CI: 0.62–0.71). Recently, a meta-analysis of patients receiving PCI + IABP with partial IMV showed that the 1 year mortality rate was 52.2% (95% CI: 0.47–0.58). In Cox regression analysis of patient data from the current study, lactic acid level ≥4.5 mmol/L, hyperuricemia, and TIMI flow <3 were independent predictors of death at 1 year. All-cause mortality, in-hospital and at 1 year, in patients with AMI-CS treated with PCI + IABP and IMV was lower than in those treated with PCI + partial IABP or IMV. Larger, longer-term direct comparisons are warranted.

Long-Term Outcomes of Acute Myocardial Infarction With Concomitant Cardiogenic Shock and Cardiac Arrest

This study sought to evaluate long-term mortality and major adverse cardiac and cerebrovascular events (MACCE) in patients with cardiac arrest (CA) and cardiogenic shock (CS) complicating acute myocardial infarction (AMI). This was a retrospective cohort study using an administrative claims database. AMI patients from January 1, 2010 to May 31, 2018 were stratified into CA + CS, CA only, CS only, and AMI alone cohorts. Outcomes of interest were long-term mortality and MACCE (death, AMI, cerebrovascular accident, unplanned revascularization) in AMI survivors. A total 163,071 AMI patients were included with CA + CS, CA only, and CS only in 2.4%, 5.0%, and 4.0%, respectively. The CA + CS cohort had higher rates of multiorgan failure, mechanical circulatory support use and less frequent coronary angiography use. In-hospital mortality was noted in 10,686 (6.6%) patients - CA + CS (48.8%), CA only (35.9%), CS only (24.1%), and AMI alone (2.9%; p < 0.001). Over 23.5 ± 21.7 months follow-up after hospital discharge, patients with CA + CS (hazard ratio [HR] 1.36 [95% confidence interval {CI} 1.19 to 1.55]), CA only (HR 1.16 [95% CI 1.08 to 1.25]), CS only (HR 1.39 [95% CI 1.29 to 1.50]) had higher all-cause mortality compared with AMI alone (all p < 0.001). Presence of CS, either alone (HR 1.22 [95% CI 1.16 to 1.29]; p < 0.001) or with CA (HR 1.18 [95% CI 1.07 to 1.29]; p < 0.001), was associated with higher MACCE compared with AMI alone. In conclusion, CA + CS, CA, and CS were associated with worse long-term survival. CA and CS continue to influence outcomes beyond the index hospitalization in AMI survivors.

Five-year risk of heart failure and death following myocardial infarction with cardiogenic shock: a nationwide cohort study

AIMS

More patients survive myocardial infarction (MI) with cardiogenic shock (CS), but long-term outcome data are sparse. We aimed to examine rates of heart failure hospitalization and mortality in MI hospital survivors.

METHODS AND RESULTS

First-time MI patients with and without CS alive until discharge were identified using Danish nationwide registries between 2005 and 2017. One-, 5-, and 1- to 5-year rates of heart failure hospitalization and mortality were compared using landmark cumulative incidence curves and Cox regression models. We identified 85 865 MI patients of whom 2865 had CS (3%). Cardiogenic shock patients were of similar age as patients without CS (median age years: 68 vs. 67), and more were men (70% vs. 65%). Cardiogenic shock was associated with a higher 5-year rate of heart failure hospitalization compared with patients without CS [40% vs. 20%, adjusted hazard ratio (HR) 2.90 (95% confidence interval (CI) 2.67-3.12)]. The increased rate of heart failure hospitalization was evident after 1 year and in the 1- to 5-year landmark analysis among 1-year survivors. All-cause mortality was higher at 1 year among CS patients compared with patients without CS [18% vs. 8%, adjusted HR 3.23 (95% CI 2.95-3.54)]. However, beyond the first year, the mortality for CS was not markedly different compared with patients without CS [12% vs. 13%, adjusted HR 1.15 (95% CI 1.00-1.33)].

CONCLUSION

Among MI hospital survivors, CS was associated with a markedly higher rate of heart failure hospitalization and 1-year mortality compared with patients without CS. However, among 1-year survivors, the remaining 5-year mortality was similar for MI patients with and without CS.

Association Between Intensive Care Unit Usage and Long-Term Medication Adherence, Mortality, and Readmission Among Initially Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction

Background

Hospitals in the United States vary in their use of intensive care units (ICUs) for hemodynamically stable patients with non–ST‐segment–elevation myocardial infarction (NSTEMI). The association between ICU use and long‐term outcomes after NSTEMI is unknown.

Methods and Results

Using data from the National Cardiovascular Data Registry linked to Medicare claims, we identified 65 256 NSTEMI patients aged ≥ 65 years without cardiogenic shock or cardiac arrest on presentation between 2011 and 2014. We compared 1‐year medication non‐adherence, cardiovascular readmission, and mortality across hospitals by ICU use using multivariable regression models. Among 520 hospitals, 154 (29.6%) were high ICU users (>70% of stable NSTEMI patients admitted to ICU), 270 (51.9%) were intermediate (30%–70%), and 196 (37.7%) were low (<30%). Compared with low ICU usage hospitals, no differences were observed in the risks of 1‐year medication non‐adherence (adjusted odds ratio 1.08, 95% CI, 0.97–1.21), mortality (adjusted hazard ratio 1.06, 95% CI, 0.98–1.15), and cardiovascular readmission (adjusted hazard ratio 0.99, 95% CI, 0.95–1.04) at high usage hospitals. Patients hospitalized at intermediate ICU usage hospitals had lower rates of evidence‐based therapy and diagnostic catheterization within 24 hours of hospital arrival, and higher risks of 1‐year mortality (adjusted hazard ratio 1.07, 95% CI, 1.02–1.12) and medication non‐adherence (adjusted odds ratio 1.09, 95% CI, 1.02–1.15) compared with low ICU usage hospitals.

Conclusions

Routine ICU use is unlikely to be beneficial for hemodynamically stable NSTEMI patients; medication adherence, long‐term mortality, and cardiovascular readmission did not differ for high ICU usage hospitals compared with hospitals with low ICU usage rates.

Outcomes of cardiogenic shock complicating acute coronary syndromes

OBJECTIVES

We aimed to assess the outcomes of cardiogenic shock (CS) complicating acute coronary syndromes (ACS).

BACKGROUND

CS remains the leading cause of mortality in patients presenting with ACS despite advances in care.

METHODS

We studied 13,184 patients undergoing percutaneous coronary intervention (PCI) for all subtypes of ACS enrolled prospectively in a large multicentre Australian registry (Melbourne Interventional Group registry) from 2005 to 2013. All-cause mortality was obtained via linkage to the National Death Index. Patients were divided into those with and those without CS.

RESULTS

Compared to the non-CS group (n = 12,548, 95.2%), the CS group (n = 636, 4.8%) had a higher proportion of out-of-hospital cardiac arrest (OHCA) (31.1 vs. 2.2%) and ST-elevation myocardial infarction (STEMI) presentation (89 vs. 34%), both p < .01. Patients in the CS group had higher rates of in-hospital (40.4 vs. 1.2%) and 30-day (41 vs. 1.7%) mortality compared to the non-CS group. Long-term mortality over a median follow-up of 4.2 years was higher in the CS group (50.6 vs. 13.8%), p < .001. Trends of in-hospital and 30-day mortality rates of CS complicating ACS were relatively stable from 2005 to 2013. Predictors of long-term NDI-linked mortality within the CS group include severe left ventricular systolic dysfunction (HR 3.0), glomerular filtration rate (GFR) <30 (HR 2.56), GFR 30-59 (HR 1.94), OHCA (HR 1.46), diabetes (HR 1.44), and age (HR 1.02), all p < .05.

CONCLUSIONS

Rates of CS-related mortality complicating ACS have remained very high and steady over nearly a decade despite progress in STEMI systems of care, PCI techniques, and medical therapy.

Admission Society for Cardiovascular Angiography and Intervention shock stage stratifies post-discharge mortality risk in cardiac intensive care unit patients

BACKGROUND

The five-stage Society for Cardiovascular Angiography and Intervention (SCAI) cardiogenic shock classification scheme can stratify hospital mortality risk in patients admitted to the cardiac intensive care unit (CICU). We sought to evaluate the SCAI shock classification for prediction of post-discharge mortality in CICU survivors.

METHODS

We retrospectively analyzed hospital survivors admitted to a single CICU between 2007 and 2015. SCAI CS stages A through E were classified using CICU admission data using a previously published algorithm. All-cause post-discharge mortality was compared across SCAI stages using Kaplan-Meier analysis and Cox proportional hazards models.

RESULTS

Among 9096 unique hospital survivors, 43.2% had acute coronary syndrome (ACS), 44.6% had heart failure (HF), and 8.7% had cardiac arrest (CA) on admission. The proportion of patients in each SCAI shock stage was: A, 49.1%; B, 30.6%; C, 15.2; D/E 5.2%. Kaplan-Meier survival at 5 years in each SCAI shock stage was: A, 88.2%; B, 81.6%; C, 76.7%; D/E, 71.7% (P < .001 by log-rank). Each higher SCAI shock stage was associated with increased adjusted post-discharge mortality compared to SCAI shock stage A (all P < .001); results were consistent among patients with ACS or HF. Late hemodynamic deterioration after 24 hours, but not an admission diagnosis of CA, was associated with higher post-discharge mortality.

CONCLUSIONS

The SCAI shock classification assessed at the time of CICU admission was predictive of post-discharge mortality risk among hospital survivors, although an admission diagnosis of CA was not. The SCAI shock classification can be used for post-discharge mortality risk stratification.

Readmissions in ST-Elevation Myocardial Infarction and Cardiogenic Shock (from Nationwide Readmission Database)

Management of ST-elevation myocardial infarction complicated by cardiogenic shock (STEMI-CS) has evolved in the last decade. There is paucity of data on readmissions in this study population. We aimed to assess the burden, major etiologies, and resource utilization for 30-day readmissions among patients with STEMI and CS. The Nationwide Readmission Database was queried from 2010 to 2014. All adult patients with an index admission for STEMI-CS were identified using International Classification of Diseases, ninth edition codes. Patient with mortality on index admission and transfers to other hospitals were excluded. A total of 18,659 admissions were identified with primary diagnosis of STEMI-CS for the study duration. Percutaneous coronary interventions was performed in 78.1% and mechanical circulatory devices were utilized in 53.9% with a mean length of stay of 10.6 (±0.2) days and mean cost of hospitalization of $47,744 (±327). Among these, 2,404 (12.9%) patients were readmitted within 30 days. Major etiologies for readmission include congestive heart failure (25.7%), acute myocardial infarction (9.4%), arrhythmias (4.5%), and sepsis (4.2%). The mean length of stay and cost of hospitalization for 30-day readmission were 5.9 (±0.3) days and $17,043 (±590), respectively. Older age, female gender, lower socioeconomic status, and discharge to home health care were significant predictors for readmission. In conclusion, there is a significant burden of 30-day readmission among patients with STEMI-CS. Percutaneous coronary interventions and mechanical circulatory devices were utilized in a majority of index admissions. Congestive heart failure was the single most common reason for 30-day readmission. Patients discharged to skilled nursing facility, patients with private insurance and higher socioeconomic status were less likely to be readmitted. Moreover, readmissions among STEMI-CS patients contribute to significant resource utilization.

Hospital participation in clinical trials for patients with acute myocardial infarction: Results from the National Cardiovascular Data Registry

BACKGROUND

Little is known about the proportion of hospitals in the United States that offer clinical trial enrollment opportunities and how patient outcomes differ between hospitals that do and do not participate in clinical trials.

METHODS

In the nationwide Chest Pain-MI registry, we described the proportion of hospitals that enrolled patients with acute myocardial infarction (MI) in clinical trials from 2009 to 2014. Hospital-level adherence to every eligible MI performance measure was compared between hospitals that did and did not enroll patients in clinical trials. Using linked Medicare data, we also compared 1-year major adverse cardiovascular events (MACE: death, MI, heart failure, or stroke) among patients ≥65 years old treated at trial versus nontrial hospitals.

RESULTS

Among 766 hospitals, 430 (56.1%) enrolled ≥1 MI patient in a clinical trial during the study period, but the proportion of hospitals enrolling patients in clinical trials declined from 36.8% in 2009 to 26.6% in 2014. Complete adherence to performance measures was delivered to a greater proportion of patients at trial hospitals than nontrial hospitals (72.6% vs 64.9%, P < .001; adjusted OR 1.07, 95% CI 1.03-1.12). One-year MACE rates were also lower for trial hospitals (adjusted HR 0.96, 95% CI 0.93-0.99).

CONCLUSIONS

Hospitals are becoming less likely to engage in clinical trials for patients with MI. Patients admitted to hospitals that participated in clinical trials more often received guideline-adherent care and had better long-term outcomes.

Temporal trends in incidence and patient characteristics in cardiogenic shock following acute myocardial infarction from 2010 to 2017: a Danish cohort study

AIM

We sought to describe the contemporary annual incidence of cardiogenic shock (CS) following acute myocardial infarction (AMICS), the proportion of patients developing CS following ST-elevation myocardial infarction (STEMI), and other temporal changes in AMICS in Denmark between 2010 and 2017.

METHODS AND RESULTS

Medical records of patients suspected of having AMICS during 2010-2017 were reviewed to identify consecutive patients with AMICS in a cohort corresponding to two-thirds of the Danish population. Due to changes in recruitment area over the study period, population-based incidence could only be calculated from 2012 to 2017. A total of 1716 patients with AMICS were identified and an increase in the annual incidence was observed, from a nadir 65.3 per million person-years in 2013 to 80.0 per million person-years in 2017 (P-value for trend < 0.001). This trend corresponded to an increase in patients with non-STEMI and a decrease in patients developing CS after STEMI (10.0-6.6%, P-value for trend < 0.001) Also, mean arterial blood pressure at the time of AMICS was lower (63 ± 11 mmHg to 61 ± 13 mmHg, P-value for trend = 0.001) and the frequency of patients with left ventricular ejection fraction ≤ 30% increased (61.8%-71.4%, P-value for trend = 0.004). The annual 30-day mortality during the study period remained unchanged at about 50%.

CONCLUSION

The incidence rate of AMICS increased in the Danish population between 2012 and 2017. Fewer patients with STEMI developed CS, and haemodynamic severity of CS increased during the study period; however, survival rates remained unchanged.

Utilization of Palliative Care for Cardiogenic Shock Complicating Acute Myocardial Infarction: A 15-Year National Perspective on Trends, Disparities, Predictors, and Outcomes

Background

This study sought to evaluate the 15‐year national utilization, trends, predictors, disparities, and outcomes of palliative care services (PCS) use in cardiogenic shock complicating acute myocardial infarction.

Methods and Results

A retrospective cohort from January 1, 2000 through December 31, 2014 was analyzed using the National Inpatient Sample database. Administrative codes for acute myocardial infarction–cardiogenic shock and PCS were used to identify eligible admissions. The primary outcomes were the frequency, utilization trends, and predictors of PCS. Secondary outcomes included in‐hospital mortality and resources utilization. Multivariable regression and propensity‐matching analyses were used to control for confounding. In this 15‐year period, there were 444 253 acute myocardial infarction–cardiogenic shock admissions, of which 4.5% received PCS. The cohort receiving PCS was older, of white race, female sex, and with higher comorbidity and acute organ failure. The PCS cohort received fewer cardiac procedures, but more noncardiac organ support therapies. Older age, female sex, white race, higher comorbidity, higher socioeconomic status, admission to a larger hospital, and admission after 2008 were independent predictors of PCS use. Use of PCS was independently associated with higher in‐hospital mortality (odds ratio 6.59 [95% CI 6.37–6.83]; P<0.001). The cohort with PCS use had >2‐fold higher in‐hospital mortality, 12‐fold higher use of do‐not‐resuscitate status, lesser in‐hospital resource utilization, and fewer discharges to home. Similar findings were observed in the propensity‐matched cohort.

Conclusions

PCS use in patients with acute myocardial infarction–cardiogenic shock is low, though there is a trend towards increased adoption. There are significant patient and hospital‐specific disparities in the utilization of PCS.

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non-ST-Segment Elevation Myocardial Infarction

Importance

Intensive care unit (ICU) utilization may have important implications for the care and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI).

Objectives

To examine interhospital variation in ICU utilization in the United States for older adults with hemodynamically stable NSTEMI and outcomes associated with ICU utilization among patients with low, moderate, or high mortality risk.

Design, Setting, and Participants

This study was a retrospective analysis of 28 018 Medicare patients 65 years or older admitted with NSTEMI to 346 hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network (ACTION)-Get With the Guidelines from April 1, 2011, through December 31, 2012. Patients with cardiogenic shock or cardiac arrest on presentation were excluded. Data analysis was performed from May 7 through October 8, 2015.

Exposures

Hospitals with high (>70% of patients with NSTEMI treated in an ICU during the index hospitalization), intermediate (30%-70%), or low (<30%) ICU utilization.

Main Outcomes and Measures

Thirty-day mortality.

Results

Of 28 018 patients with NSTEMI 65 years or older (median age, 77 years [interquartile range, 71-84 years]; female, 13 055 [46.6%]; nonwhite race, 3931 [14.0%]), 11 934 (42.6%) had an ICU stay. The proportion of patients with NSTEMI treated in the ICU varied across hospitals (median, 38%; interquartile range, 26%-54%), but no significant differences were found in hospital or patient characteristics among high, intermediate, or low ICU utilization hospitals. Compared with high ICU utilization hospitals, low or intermediate ICU utilization hospitals were only marginally more selective of higher-risk patients, as determined by ACTION in-hospital mortality risk score or initial troponin level. The median ACTION risk score for patients treated in the ICU at low and intermediate ICU utilization hospitals was 34 compared with 33 for patients not treated in the ICU; at high ICU utilization hospitals, the median ACTION mortality risk score was 33 for patients treated in the ICU and 34 for patients not treated in the ICU. Thirty-day mortality rates did not significantly differ based on hospital ICU utilization (high vs low: 8.7% vs 8.7%; adjusted odds ratio, 0.91; 95% CI, 0.76-1.08; intermediate vs low: 9.6% vs 8.7%; adjusted odds ratio, 1.06; 95% CI, 0.94-1.20). The association between hospital ICU utilization and mortality did not change when considered among patients with ACTION risk scores greater than 40, 30 to 40, and less than 30 (adjusted interaction P = .86).

Conclusions and Relevance

Utilization of the ICU for older patients with NSTEMI varied significantly among hospitals. This variability was not explained by hospital characteristics or driven by patient risk. Mortality after myocardial infarction did not significantly differ among high, intermediate, or low ICU utilization hospitals.

Efficacy and Safety of Ticagrelor Compared with Clopidogrel in Patients with End-Stage Renal Disease with Acute Myocardial Infarction

OBJECTIVE

This study investigated the efficacy and safety of ticagrelor compared with clopidogrel in patients with end-stage renal disease (ESRD) and acute myocardial infarction (AMI).

METHODS

We retrospectively enrolled patients who had received regular dialysis and had undergone percutaneous coronary intervention (PCI) for AMI at our hospital between January 2013 and December 2016. Outcomes analyzed included cardiovascular death, death from any cause, MI, stroke, and bleeding events.

RESULT

Patients were allocated to the ticagrelor group (N = 74) or the clopidogrel group (N = 116) according to the treatment they had received. No statistically significant differences were found between the groups in terms of in-hospital primary endpoint (composite of cardiovascular death, MI, and stroke: 12.2% and 15.5% for ticagrelor and clopidogrel, respectively; p = 0.518), secondary endpoint, or any bleeding events (39.2 vs. 34.5%; p = 0.511). No statistically significant differences were found for the 1-year primary endpoint (p = 0.424), secondary endpoint, and any bleeding events (p = 0.663). Risk factors for in-hospital cardiovascular death were shock and cardiopulmonary resuscitation at initial AMI presentation, lack of beta-blocker use, and in-hospital gastrointestinal bleeding. Risk factors for 1-year cardiovascular death were shock at initial AMI presentation and lack of beta-blocker use. Only respiratory failure was a risk factor for in-hospital and 1-year gastrointestinal bleeding.

CONCLUSION

In patients with ESRD and AMI, ticagrelor resulted in numerically fewer but statistically nonsignificant rates of in-hospital and 1-year cardiovascular events with no significant increase in bleeding events compared with clopidogrel.