Diabetes mellitus and cardiogenic shock in acute myocardial infarction

Trends and Outcomes of Cardiogenic Shock in Patients With End-Stage Renal Disease: Insights From USRDS Database

BACKGROUND

There is a paucity of data regarding epidemiology, temporal trends, and outcomes of patients with cardiogenic shock (CS) and end-stage renal disease (chronic kidney disease stage V on hemodialysis).

METHODS

This is a retrospective cohort study using the United States Renal Data System database from January 1, 2006 to December 31, 2019. We analyzed trends of CS, percutaneous mechanical support (intraaortic balloon pump, percutaneous ventricular assist device [Impella and Tandemheart], and extracorporeal membrane oxygenation) utilization, index mortality, 30-day mortality, and 1-year all-cause mortality in end-stage renal disease patients.

RESULTS

A total of 43 825 end-stage renal disease patients were hospitalized with CS (median age, 67.8 years [IQR, 59.4-75.8] and 59.1% men). From 2006 to 2019, the incidence of CS increased from 275 to 578 per 100 000 patients (Ptrend<0.001). The index mortality rate declined from 54.1% in 2006 to 40.8% in 2019 (Ptrend=0.44), and the 1-year all-cause mortality decreased from 63% in 2006 to 61.8% in 2018 (Ptrend=0.73), but neither trend was statistically significant. There was a significantly decreased utilization of intra-aortic balloon pumps from 17 832 to 7992 (Ptrend<0.001), increased utilization of percutaneous ventricular assist device from 137 to 5201 (Ptrend<0.001) and increase in extracorporeal membrane oxygenation use from 69 to 904 per 100 000 patients (Ptrend<0.001). After adjusting for covariates, there was no significant difference in index mortality between CS patients requiring percutaneous mechanical support versus those not requiring percutaneous mechanical support (odds ratio, 0.97 [CI, 0.91-1.02]; P=0.22). On multivariable regression analysis, older age, peripheral vascular disease, diabetes, and time on dialysis were independent predictors of higher index mortality.

CONCLUSIONS

The incidence of CS in end-stage renal disease patients has doubled without significant change in the trend of index mortality despite the use of percutaneous mechanical support.

Impact of diabetes on outcomes of cardiogenic shock: A systematic review and meta-analysis

To provide synthesized evidence on the association of diabetes with clinical outcomes of patients with acute myocardial infarction (AMI) and associated cardiogenic shock (CS). We analyzed observational studies on patients with AMI and CS, identified through a systematic search using PubMed and Scopus databases. The main outcome was mortality and other outcomes of interest were risk of major bleeding, re-infarction, cerebrovascular adverse events, and need for revascularization. We conducted the meta-analysis with data from 15 studies. Compared to patients without diabetes, those with diabetes had an increased risk of in-hospital mortality (OR, 1.34; 95% CI, 1.17-1.54) and cerebrovascular complications (OR, 1.28; 95% CI, 1.11-1.48). We found similar risk of major bleeding (OR, 0.68; 95% CI, 0.43-1.09), re-infarction (OR, 0.98; 95% CI, 0.48-1.98) and need for re-vascularization (OR, 0.96; 95% CI, 0.75-1.22) as well as hospital stay lengths (in days) (WMD 0.00; 95% CI, -0.27-0.28; n = 4; I² = 99.7%) in the two groups of patients. Patients with diabetes, acute MI and associated cardiogenic shock have increased risks of mortality and adverse cerebrovascular events than those without diabetes.

Cardiogenic Shock Among Patients with and without Acute Myocardial Infarction in a Latin American Country: A Single-Institution Study

Background:

Latin America has limited information about the full spectrum cardiogenic shock (CS) and its hospital outcome. This study sought to examine the temporal trends, clinical features and outcomes of patients with CS in a coronary care unit of single Mexican institution.

Methods:

This was a retrospective study of consecutive patients hospitalized with CS in a Mexican teaching hospital between 2006–2019. Patients were classified according to the presence or absence of acute myocardial infarction (AMI).

Results:

Of 22,747 admissions, 833 (3.7%) exhibited CS. Among patients with AMI (n = 12,438), 5% had AMI–CS, and in patients without AMI (n = 10,309), 2.3% developed CS (non-AMI–CS). Their median age was 63 years and 70.5% were men. Cardiovascular risk factors were more frequent among the AMI–CS group, whereas a history of heart failure was greater in non-AMI–CS patients (70.1%). In AMI-CS patients, the median delay time was 17.2 hours from the onset of AMI symptoms to hospital admission. Overall, the median left ventricular ejection fraction (LVEF) was 30%. Patients with CS at admission showed end-organ dysfunction, evidenced by lactic acidosis, renal impairment, and elevated liver transaminases. Of the 620 AMI–CS patients, the main cause was left ventricular dysfunction in 71.3%, mechanical complications in 15.2% and right ventricular infarction in 13.5%. Among the 213 non-AMI–CS patients, valvular heart disease (49.3%) and cardiomyopathies (42.3%) were the most frequent etiologies. In-hospital all-cause mortality rates were 69.7% and 72.3% in the AMI–CS and non-AMI–CS groups, respectively. Among AMI–CS patients, renal dysfunction, diabetes, older age, depressed LVEF, absence of revascularization and the use of mechanical ventilation were independent predictors of in-hospital mortality. However, in the non-AMI–CS group, only low LVEF and high lactate levels proved significant.

Conclusions:

This study demonstrates differences in the epidemiology of CS compared to high-income countries; the high mortality reflects critically ill patients and the lack of contemporary effective therapies in the population studied.

Admission biomarkers among patients with acute myocardial-infarction related cardiogenic shock with or without out-of-hospital cardiac arrest an exploratory study

BACKGROUND

Acute myocardial infarction complicated by cardiogenic shock (AMICS) with or without out-of-hospital cardiac arrest (OHCA) have some pathophysiological differences and could potentially be considered as two individual clinical entities. Thus, there may also be differences in terms of blood borne biomarkers.

PURPOSE

To explore potential differences in concentrations of the biomarkers lactate, mid-regional proadrenomedullin (MRproADM), Copeptin, pro-atrial natriuretic peptide (proANP), Syndecan-1, soluble thrombomodulin (sTM), soluble suppression of tumorigenicity 2 (sST2) and neutrophil gelatinase-associated lipocalin (NGAL), in patients with AMICS with or without OHCA.

METHOD

Patients admitted for acute coronary angiography due to suspected ST-elevation myocardial infarction were enrolled during a 1-year period. In the present study 86 patients with confirmed AMICS at admission were included.

RESULTS

In the adjusted analysis OHCA patients had higher levels of lactate (p = 0.008), NGAL (p = 0.03) and sTM (p = 0.011) while the level of sST2 was lower (p = 0.029). There was little difference in 30-day mortality between the OHCA and non-OHCA groups (OHCA 37% vs. non-OHCA 38%).

CONCLUSION

AMICS patients with or without OHCA had similar 30-day mortality but differed in terms of Lactate, NGAL, sTM and sST2 levels. These findings support that non-OHCA and OHCA patients with CS could be considered as two individual clinical entities.

Diabetes mellitus, revascularization and outcomes in elderly patients with myocardial infarction-related cardiogenic shock

Background

The prognostic role of diabetes mellitus (DM) in elderly patients with myocardial infarction-related cardiogenic shock (MI-CS) remains controversial. Little information exists about the impact of intensive cardiac care unit (ICCU) and revascularization on outcomes of elderly patients with MI-CS. We aimed to assess the prognostic impact of DM according to age in patients with MI-CS, and to analyze the impact ICCU management and revascularization on in-hospital mortality in MI-CS patients at older ages.

Methods

Discharge episodes with diagnosis of CS associated with MI were selected from the Spanish National Health System's Basic Data Set. Centers were classified according to their availability of ICCU. Main outcome measured was in-hospital mortality.

Results

A total of 23, 590 episodes of MI-CS were identified, of whom 12, 447 (52.8%) were in patients aged ≥ 75 years. The impact of DM on in-hospital mortality was different among age subgroups. While in younger patients, DM was associated to a higher mortality risk (0.52 vs. 0.47, OR = 1.12, 95% CI: 1.06-1.18, χ² < 0.001), this association became non-significant in older patients (0.76 vs. 0.81, χ² = 0.09). Adjusted mortality rate of MI-CS aged ≥ 75 years was lower in patients admitted to hospitals with ICCU (adjusted mortality rate: 74.2% vs. 77.7%, P < 0.001) and in patients undergoing revascularization (74.9% vs. 77.3%, P < 0.001).

Conclusions

Prognostic impact of DM in patients with MI-CS was different according to age, with a significantly lower impact at older ages. The availability of ICCU and revascularization were associated with better outcomes in these complex patients.

The association of diabetes and admission blood glucose with 30-day mortality in patients with acute myocardial infarction complicated by cardiogenic shock

BACKGROUND

Cardiogenic shock is the leading cause of death in patients with acute myocardial infarction, with short-term mortality of approximately 50%. Whether diabetes mellitus and high blood glucose levels are associated with mortality in contemporary patients with acute myocardial infarction complicated by cardiogenic shock is inadequately described.

PURPOSE

To investigate if diabetes mellitus and high admission blood glucose were associated with 30-day mortality in a large, contemporary population with acute myocardial infarction complicated by cardiogenic shock.

METHODS

Patients with acute myocardial infarction complicated by cardiogenic shock admitted at two tertiary centres in Denmark from 2010 to 2017 were individually identified through patient charts, resulting in the inclusion of 1716 cardiogenic shock patients. Glucose level at admission to the intensive care unit was available in 1302 patients.

RESULTS

There was no significant difference in 30-day mortality between diabetes mellitus types I and II (63% vs. 62%, NS). Thirty-day mortality was significantly higher in diabetes patients compared to non-diabetes patients (62% vs. 50%, P < 0.001). Increasing admission glucose was associated with increasing 30-day mortality in a dose-dependent manner in diabetes mellitus (4-8 mmol/L, 41%; 8-12 mmol/L, 49%; 12-16 mmol/L, 63%; >16 mmol/L, 67%; P = 0.028) and non-diabetes patients (4-8 mmol/L, 32%; 8-12 mmol/L, 43%; 12-16 mmol/L, 57%; >16 mmol/l; 68%; P < 0.001).

CONCLUSION

Patients with acute myocardial infarction complicated by cardiogenic shock and concomitant diabetes mellitus type I or II had a significantly higher 30-day mortality in comparison to patients without diabetes mellitus, whereas no difference was found between diabetes mellitus types I and II. High glucose levels on admission to the intensive care unit were associated with increased 30-day mortality in diabetes mellitus and non-diabetes mellitus patients.

Nitroxyl: A Novel Strategy to Circumvent Diabetes Associated Impairments in Nitric Oxide Signaling

Diabetes is associated with an increased mortality risk due to cardiovascular complications. Hyperglycemia-induced oxidative stress underlies these complications, leading to an impairment in endogenous nitric oxide (NO•) generation, together with reductions in NO• bioavailability and NO• responsiveness in the vasculature, platelets and myocardium. The latter impairment of responsiveness to NO•, termed NO• resistance, compromises the ability of traditional NO•-based therapeutics to improve hemodynamic status during diabetes-associated cardiovascular emergencies, such as acute myocardial infarction. Whilst a number of agents can ameliorate (e.g. angiotensin converting enzyme [ACE] inhibitors, perhexiline, statins and insulin) or circumvent (e.g. nitrite and sGC activators) NO• resistance, nitroxyl (HNO) donors offer a novel opportunity to circumvent NO• resistance in diabetes. With a suite of vasoprotective properties and an ability to enhance cardiac inotropic and lusitropic responses, coupled with preserved efficacy in the setting of oxidative stress, HNO donors have intact therapeutic potential in the face of diminished NO• signaling. This review explores the major mechanisms by which hyperglycemia-induced oxidative stress drives NO• resistance, and the therapeutic potential of HNO donors to circumvent this to treat cardiovascular complications in type 2 diabetes mellitus.

Predictors of Outcomes in Myocardial Infarction and Cardiogenic Shock

Myocardial infarction (MI) complicated by cardiogenic shock (MI-CS) is a major cause of cardiovascular morbidity and mortality. Predictors of outcomes in MI-CS include clinical, laboratory, radiologic variables, and management strategies. This article reviews the existing literature on short- and long-term predictors and risk stratification in MI complicated by CS.

Diabetes Mellitus and Cardiogenic Shock Complicating Acute Myocardial Infarction

BACKGROUND

Diabetes mellitus (diabetes) increases the risk of acute myocardial infarction, which can result in cardiogenic shock. Data on the relation of diabetes and the occurrence and prognosis of cardiogenic shock postacute myocardial infarction are scant.

METHODS

Among the National Inpatient Sample patients aged ≥18 years and hospitalized for acute myocardial infarction during the 2012-2014 period, we examined the association between diabetes and the incidence and outcomes of cardiogenic shock complicating acute myocardial infarction, using multivariable logistic and linear regression models.

RESULTS

Of 1,332,530 hospitalizations for acute myocardial infarction, 72,765 (5.5%) were complicated by cardiogenic shock. In acute myocardial infarction patients, cardiogenic shock incidence was higher among those with vs without diabetes (5.8% vs 5.2%; adjusted odds ratio [aOR] 1.14; 95% confidence interval [CI], 1.11-1.19; P < .001), with 42.8% (n = 31,135) of patients with acute myocardial infarction and cardiogenic shock having diabetes. Diabetic patients were less likely to undergo revascularization (percutaneous coronary intervention or coronary artery bypass grafting) (67.1% vs 68.7%; aOR 0.88; 95% CI, 0.80-0.96; P = .003). Diabetes was associated with higher in-hospital mortality in patients with acute myocardial infarction and cardiogenic shock (37.9% vs 36.8%; aOR 1.18; 95% CI, 1.09-1.28; P < .001). Among survivors, patients with diabetes had a longer hospital stay (mean ± SEM: 11.6 ± 0.16 vs 10.9 ± 0.16 days; adjusted estimate 1.12; 95% CI, 1.06-1.18; P < .001) and were more likely to be discharged to a skilled nursing home or with home health care (56.0% vs 50.5%; aOR 1.19; 95% CI, 1.07-1.33; P = .001).

CONCLUSIONS

In a large cohort of acute myocardial infarction patients, preexisting diabetes was associated with an increased risk of cardiogenic shock and worse outcomes in those with cardiogenic shock.

Impact of intra-aortic balloon pump on short-term clinical outcomes in ST-elevation myocardial infarction complicated by cardiogenic shock: A "real life" single center experience

OBJECTIVE

To analyze the use and impact of the intra-aortic balloon pump (IABP) upon the 30-day mortality rate and short-term clinical outcome of non-selected patients with ST-elevation acute myocardial infarction (acute STEMI) complicated by cardiogenic shock (CS).

DESIGN

A single-center retrospective case-control study was carried out.

SETTING

Coronary Care Unit.

PATIENTS

Data were collected from 825 consecutive patients with acute STEMI admitted to a Coronary Care Unit from January 2009 to August 2015. Seventy-three patients with CS upon admission subjected to emergency percutaneous coronary intervention (PCI) were finally included in the analysis and were stratified according to IABP use (44 patients receiving IABP).

VARIABLES

Cardiovascular history, hemodynamic situation upon admission, angiographic and procedural characteristics, and variables derived from admission to the Coronary Care Unit.

RESULTS

Cumulative 30-day mortality was similar in the patients subjected to IABP and in those who received conventional medical therapy only (29.5% and 27.6%, respectively; HR with IABP 1.10, 95% CI 0.38-3.11; p=0.85). Similarly, no significant differences were found in terms of the short-term clinical outcome between the groups: time on mechanical ventilation, days to hemodynamic stabilization, vasoactive drug requirements and stay in the Coronary Care Unit. Poorer renal function (HR 3.9, 95% CI 1.4-10.6; p=0.008), known peripheral artery disease (HR 3.3, 95% CI 1.2-9.1; p=0.019) and a history of diabetes mellitus (HR 3.2, 95% CI 1.2-8.1; p=0.018) were the only variables independently associated to increased 30-day mortality.

CONCLUSION

In our "real life" experience, IABP does not modify 30-day mortality or the short-term clinical outcome in patients presenting STEMI complicated with CS and subjected to emergency percutaneous coronary revascularization.

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.

Decade-long trends in the characteristics, management and hospital outcomes of diabetic patients with ST-segment elevation myocardial infarction

PURPOSE

Our objectives were to describe recent trends in the characteristics and in-hospital outcomes in diabetic as compared with non-diabetic patients hospitalized with ST-segment elevation myocardial infarction (STEMI).

METHODS

We reviewed the medical records of 2537 persons with (n = 684) and without (n = 1853) a history of diabetes who were hospitalized for STEMI between 1997 and 2009 at 11 medical centres in Central Massachusetts.

RESULTS

Diabetic patients were more likely to be older, female and to have a higher prevalence of previously diagnosed comorbidities. Diabetic patients were more likely to have developed important in-hospital complications and to have a longer hospital stay compared with non-diabetic patients. Between 1997 and 2009, there was a marked decline in hospital mortality in diabetic (20.0%-5.6%) and non-diabetic (18.6%-7.5%) patients.

CONCLUSION

Despite reduced hospital mortality in patients hospitalized with STEMI, diabetic patients continue to experience significantly more adverse outcomes than non-diabetics.

A review of cardiogenic shock in acute myocardial infarction

Cardiogenic shock continues to be the most common cause of death in patients hospitalized with acute myocardial infarction. It has also been frequently associated with ST-segment elevation myocardial infarction (STEMI) and patients with co-morbidities. Cardiogenic shock presents with low systolic blood pressure and clinical signs of hypoperfusion. Rapid diagnosis and supportive therapy in the form of medications, airway support and intra-aortic balloon counterpulsation is required. Initial stabilization can be followed by reperfusion by fibrinolytic therapy, emergent percutaneous intervention (PCI) or coronary artery bypass grafting (CABG). The latter two have been found to decrease mortality in the long term. Research is being carried out on the role of inflammatory mediators in the clinical manifestation of cardiogenic shock. Mechanical support devices also show promise in the future.