DOI: https://doi.org/10.21203/rs.3.rs-841985/v1
Background: Acute myocardial infarction (AMI) complicated with cardiogenic shock has high mortality and is a challenging topic even in the revascularization era. We conducted this study to understand patients’ outcomes.
Method: We retrospectively analyzed electronic medical records data from 1,175 patients with AMI complicated with cardiogenic shock developed within 3 days of admission to a multicenter medical care system between January 1, 2000, and July 31, 2018. AMI patients were classified into ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) group. The short-term and 1-year mortality and adverse event after the index admission were analyzed via logistic regression and Cox proportional hazards model.
Results: Comparing to NSTEMI, patients with STEMI tended to be younger (65.68 ± 14.05 vs. 70.70 ± 12.99, p < .001), men (73.29 vs. 60.87, p < .001), and have fewer underlying chronic diseases. Short-term mortality at index hospitalization was 14.83% in the STEMI group and 21.30% in the NSTEMI group; long-term mortality was 17.06% for the STEMI group and 24.13% for the NSTEMI group. No difference was observed between the 2 groups for patients who developed a cerebral vascular accident (CVA) during the admission period; however, the major bleeding rate and gastrointestinal bleeding rate were higher in the STEMI group (2.66 vs. 0.22, p = .014; 3.36 vs. 0.22, p = .007, respectively).
Conclusion: In patients with AMI with cardiogenic shock, NSTEMI was associated with a significantly higher mortality rate in both the short-and long-term results. Age and respiratory failure were the most significant risk factors for short-term mortality. Revascularization may be beneficial for the short-term outcome but did not reach significance in multivariable analysis.
Table 1. Baseline clinical characteristics of the patients.
|
|
All |
STEMI |
NSTEMI |
p-value |
|
|
N=1,175 |
N=715 |
N=460 |
|
|
Characteristics |
|
|
|
|
|
Age, year^ |
67.65±13.86 |
65.68±14.05 |
70.70±12.99 |
<.001 |
|
Gender# |
|
|
|
<.001 |
|
Male |
804 (68.43) |
524 (73.29) |
280 (60.87) |
|
|
Female |
371 (31.57) |
191 (26.71) |
180 (39.13) |
|
|
Treatment |
|
|
|
|
|
IABP use# |
274 (23.32) |
175 (24.48) |
99 (21.52) |
0.243 |
|
ECMO use# |
68 (5.79) |
49 (6.85) |
19 (4.13) |
0.051 |
|
ECMO days^ |
2.50±0.95 |
2.35±0.93 |
2.89±0.94 |
0.033 |
|
PCI# |
481 (40.94) |
296 (41.40) |
185 (40.22) |
0.688 |
|
CABG# |
99 (8.43) |
56 (7.83) |
43 (9.35) |
0.361 |
|
Intubation# |
182 (15.49) |
100 (13.99) |
82 (17.83) |
0.076 |
|
Inotropes treatment# |
|
|
|
|
|
Dopamine |
716 (60.94) |
502 (70.21) |
214 (46.52) |
<.001 |
|
Dobutamine |
162 (13.79) |
107 (14.97) |
55 (11.96) |
0.144 |
|
Norepinephrine |
474 (40.34) |
238 (33.29) |
236 (51.30) |
<.001 |
|
Epinephrine |
288 (24.51) |
168 (23.50) |
120 (26.09) |
0.314 |
|
Comorbidity# |
|
|
|
|
|
OHCA |
81 (6.89) |
61 (8.53) |
20 (4.35) |
0.006 |
|
Diabetes |
348 (29.62) |
155 (21.68) |
193 (41.96) |
<.001 |
|
Insulin-requiring |
289 (24.6) |
109 (15.24) |
180 (39.13) |
<.001 |
|
Hypertension |
484 (41.19) |
240 (33.57) |
244 (53.04) |
<.001 |
|
Hyperlipidemia |
347 (29.53) |
182 (25.45) |
165 (35.87) |
<0.001 |
|
Atrial fibrillation |
52 (4.43) |
24 (3.36) |
28 (6.09) |
0.026 |
|
COPD |
177 (15.06) |
75 (10.49) |
102 (22.17) |
<.001 |
|
CKD |
230 (19.57) |
75 (10.49) |
155 (33.7) |
<.001 |
|
ESRD on dialysis |
134 (11.4) |
37 (5.17) |
97 (21.09) |
<.001 |
|
PAOD |
80 (6.81) |
28 (3.92) |
52 (11.3) |
<.001 |
|
Gout |
140 (11.91) |
61 (8.53) |
79 (17.17) |
<.001 |
|
Malignancy |
104 (8.85) |
53 (7.41) |
51 (11.09) |
0.030 |
|
Previous HF |
212 (18.04) |
90 (12.59) |
122 (26.52) |
<.001 |
|
Previous MI |
181 (15.4) |
85 (11.89) |
96 (20.87) |
<.001 |
|
Previous CVA |
219 (18.64) |
100 (13.99) |
119 (25.87) |
<.001 |
|
Previous PCI |
146 (12.43) |
63 (8.81) |
83 (18.04) |
<.001 |
|
Previous CABG |
22 (1.87) |
10 (1.4) |
12 (2.61) |
0.135 |
|
Lab& median (IQR) |
|
|
|
|
|
Hb |
12.45(4) |
13.2(3.7) |
11.2(3.6) |
<.001 |
|
Cr |
1.47(1.24) |
1.36(0.92) |
1.725(2.46) |
<.001 |
|
Na |
138(5) |
138(5) |
138(6) |
0.007 |
|
K |
4(0.9) |
3.9(0.8) |
4(1) |
0.056 |
|
ALT |
41(63) |
51(88) |
31(40) |
<.001 |
|
CRP |
44.36(110.2) |
44.4(109.2) |
44.36(112.4) |
0.705 |
|
Index admission days^ |
12.73±11.04 |
12.19±10.79 |
13.56±11.39 |
0.038 |
^ t test; # χ2 test; & Kruskal-Wallis test; ALT: alanine aminotransferase; CABG: coronary artery bypass grafting; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; Cr: serum creatinine; CRP: C-reactive protein; CVA: cerebral vascular accident; ECMO: extracorporeal membrane oxygenation; ESRD: end-stage renal disease; Hb: serum hemoglobin; HF: heart failure; IABP: intra-aortic balloon pump; K: serum potassium; MI: myocardial infarction; Na: serum sodium; OHCA: Out-of-hospital cardiac arrest; PAOD: peripheral artery occlusive disease; PCI: percutaneous coronary intervention
Table 2. Outcomes for 30-day or index hospitalization mortality.
|
|
Number of event (%) |
OR (95% CI)* |
P |
|
|
Outcome |
STEMI N=715 |
NSTEMI N=460 |
||
|
Primary Outcomes |
|
|
|
|
|
30 days or index hospitalization mortality |
106 (14.83) |
98 (21.30) |
1.56 (1.15-2.11) |
0.004 |
|
30 days mortality |
102 (14.27) |
88 (19.13) |
1.42 (1.04-1.94) |
0.028 |
|
Mortality at index hospitalization |
106 (14.83) |
97 (21.09) |
1.54 (1.13-2.08) |
0.006 |
|
Secondary Outcomes |
|
|
|
|
|
New onset of dialysis |
22 (3.08) |
37 (8.04) |
0.36 (0.21-0.63) |
<.001 |
|
New onset of CVA |
|
|
|
|
|
Ischemic stroke |
9 (1.26) |
8 (1.74) |
0.72 (0.28-1.89) |
0.503 |
|
Hemorrhagic stroke |
5 (0.70) |
1 (0.22) |
3.22 (0.38-25.0) |
0.285 |
|
Major bleeding |
19 (2.66) |
1 (0.22) |
12.5 (1.67-100.0) |
0.014 |
|
Gastrointestinal bleeding |
24 (3.36) |
1 (0.22) |
16.7 (2.13-100.0) |
0.007 |
|
Pneumonia |
133 (18.60) |
109 (23.70) |
0.74 (0.55-0.98) |
0.035 |
|
Sepsis |
139 (19.44) |
148 (32.17) |
0.51 (0.39-0.67) |
<.001 |
*Ref. = SETMI; CVA: cerebral vascular accident
Table 3. Outcomes for 1-year follow-up cases.
|
|
Number of event (%) |
HR (95% CI)* |
P |
|
|
Outcome |
STEMI N=609 |
NSTEMI N=363 |
||
|
CV outcome |
|
|
|
|
|
Myocardial infarction |
|
|
|
|
|
STEMI |
10 (1.64) |
4 (1.10) |
0.67 (0.21-2.13) |
0.497 |
|
NSTEMI |
10 (1.64) |
16 (4.41) |
2.72 (1.24-6.00) |
0.013 |
|
Revascularization |
|
|
|
|
|
PCI |
58 (9.52) |
20 (5.51) |
0.56 (0.34-0.94) |
0.027 |
|
CABG |
4 (0.66) |
4 (1.10) |
1.68 (0.42-6.73) |
0.461 |
|
Heart failure admission |
55 (9.03) |
47 (12.95) |
1.46 (0.99-2.15) |
0.057 |
|
Death from any cause |
16 (2.63) |
15 (4.13) |
1.58 (0.78-3.20) |
0.202 |
|
Neurologic outcome |
|
|
|
|
|
Ischemic stroke |
3 (0.49) |
1 (0.28) |
0.56 (0.06-5.36) |
0.613 |
|
Hemorrhagic stroke |
1 (0.16) |
1 (0.28) |
1.68 (0.11-26.8) |
0.715 |
|
Unspecified stroke |
9 (1.48) |
7 (1.93) |
1.31 (0.49-3.52) |
0.592 |
|
Safety outcome |
|
|
|
|
|
Major bleeding |
3 (0.49) |
1 (0.28) |
0.56 (0.06-5.38) |
0.615 |
|
GI bleeding |
4 (0.66) |
1 (0.28) |
0.42 (0.05-3.75) |
0.437 |
*Ref. = SETMI; CABG: coronary artery bypass grafting; CV: cardiovascular; GI: gastrointestinal; PCI: percutaneous coronary intervention
Table 4a. Subgroup analysis of predictors of 30-day or in-hospital mortality in ST-elevation myocardial infarction (STEMI).
|
|
Univariate analysis |
Multivariate analysis |
||||
|
Variables |
HR |
95% CI |
p-value |
HR |
95% CI |
p-value |
|
Age, > 65 yrs |
1.91 |
(1.27-2.86) |
0.002 |
1.67 |
(1.10-2.56) |
0.017 |
|
Male |
0.53 |
(0.36-0.79) |
0.002 |
0.64 |
(0.43-0.96) |
0.031 |
|
Treatment |
|
|
|
|
|
|
|
IABP use |
1.1 |
(0.71-1.69) |
0.670 |
- |
- |
- |
|
ECMO use |
2.58 |
(1.51-4.40) |
0.001 |
3.11 |
(1.79-5.39) |
<.001 |
|
ECMO days |
0.61 |
(0.34-1.08) |
0.089 |
- |
- |
- |
|
Intubation |
2.23 |
(1.45-3.44) |
0.0003 |
1.99 |
(1.28-3.10) |
0.002 |
|
Revascularization |
0.35 |
(0.23-0.54) |
<.0001 |
0.45 |
(0.18-1.12) |
0.085 |
|
PCI |
0.35 |
(0.22-0.56) |
<.0001 |
0.76 |
(0.29-2.03) |
0.589 |
|
CABG |
0.75 |
(0.35-1.63) |
0.472 |
- |
- |
- |
|
Comorbidity |
|
|
|
|
|
|
|
Diabetes mellitus |
0.93 |
(0.58-1.49) |
0.763 |
- |
- |
- |
|
Insulin-requiring |
1.06 |
(0.63-1.78) |
0.834 |
- |
- |
- |
|
Hypertension |
1.38 |
(0.94-2.03) |
0.104 |
- |
- |
- |
|
Hyperlipidemia |
0.94 |
(0.60-1.46) |
0.775 |
- |
- |
- |
|
Atrial fibrillation |
2.06 |
(0.96-4.43) |
0.065 |
- |
- |
- |
|
COPD |
1.32 |
(0.75-2.32) |
0.333 |
- |
- |
- |
|
CKD |
1.2 |
(0.67-2.15) |
0.537 |
- |
- |
- |
|
PAOD |
1.58 |
(0.69-3.61) |
0.275 |
- |
- |
- |
|
Gout |
0.86 |
(0.42-1.77) |
0.682 |
- |
- |
- |
|
Malignancy |
1.44 |
(0.77-2.70) |
0.249 |
- |
- |
- |
|
Previous CABG |
0.7 |
(0.10-4.98) |
0.719 |
- |
- |
- |
|
Dialysis |
1.76 |
(0.89-3.49) |
0.105 |
- |
- |
- |
Adjusted variable: Age group, gender, ECMO use, Intubation, Revascularization, PCI; CABG: coronary artery bypass grafting; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; ECMO: extracorporeal membrane oxygenation; IABP: intra-aortic balloon pump; PAOD: peripheral artery occlusive disease; PCI: percutaneous coronary intervention
Table 4b. Subgroup analysis of predictors of 30-day or in-hospital mortality in non-ST-elevation myocardial infarction (NSTEMI).
|
|
Univariate analysis |
Multivariate analysis |
||||
|
Variables |
HR |
95% CI |
p-value |
HR |
95% CI |
p-value |
|
Age, > 65 yrs |
2.99 |
(1.72-5.19) |
<.0001 |
2.66 |
(1.52-4.67) |
0.001 |
|
Male |
0.68 |
(0.46-1.01) |
0.057 |
- |
- |
- |
|
Treatment |
|
|
|
|
|
|
|
IABP use |
1.08 |
(0.68-1.73) |
0.745 |
- |
- |
- |
|
ECMO use |
1.23 |
(0.50-3.03) |
0.648 |
- |
- |
- |
|
ECMO days |
0.72 |
(0.30-1.74) |
0.467 |
- |
- |
- |
|
Intubation |
2.03 |
(1.31-3.14) |
0.002 |
2.17 |
(1.39-3.37) |
0.001 |
|
Revascularization |
0.37 |
(0.24-0.57) |
<.0001 |
0.73 |
(0.33-1.63) |
0.445 |
|
PCI |
0.37 |
(0.23-0.60) |
<.0001 |
0.52 |
(0.22-1.23) |
0.135 |
|
CABG |
0.75 |
(0.36-1.56) |
0.447 |
- |
- |
- |
|
Comorbidity |
|
|
|
|
|
|
|
Diabetes mellitus |
1.47 |
(0.99-2.18) |
0.058 |
- |
- |
- |
|
Insulin-requiring |
1.38 |
(0.93-2.06) |
0.111 |
- |
- |
- |
|
Hypertension |
1.35 |
(0.91-2.03) |
0.140 |
- |
- |
- |
|
Hyperlipidemia |
1.33 |
(0.89-1.99) |
0.166 |
- |
- |
- |
|
Atrial fibrillation |
1.57 |
(0.76-3.23) |
0.224 |
- |
- |
- |
|
COPD |
1.36 |
(0.87-2.14) |
0.177 |
- |
- |
- |
|
CKD |
1.82 |
(1.22-2.71) |
0.003 |
1.28 |
(0.83-1.98) |
0.271 |
|
PAOD |
1.49 |
(0.87-2.56) |
0.146 |
- |
- |
- |
|
Gout |
1.79 |
(1.13-2.84) |
0.013 |
1.43 |
(0.86-2.37) |
0.171 |
|
Malignancy |
1.72 |
(1.01-2.94) |
0.047 |
1.11 |
(0.64-1.93) |
0.709 |
|
Previous CABG |
0.74 |
(0.18-2.99) |
0.670 |
- |
- |
- |
|
Dialysis |
1.52 |
(0.98-2.37) |
0.064 |
- |
- |
- |
Adjusted variable: Age group, Intubation, Revascularization, PCI, CKD, Gout, Malignancy CABG: coronary artery bypass grafting; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; ECMO: extracorporeal membrane oxygenation; IABP: intra-aortic balloon pump; PAOD: peripheral artery occlusive disease; PCI: percutaneous coronary intervention