Cardiogenic Shock From Heart Failure Versus Acute Myocardial Infarction: Clinical Characteristics, Hospital Course, and 1-Year Outcomes

Abstract

Background: Little is known about clinical characteristics, hospital course, and longitudinal outcomes of patients with cardiogenic shock (CS) related to heart failure (HF-CS) compared to acute myocardial infarction (AMI; CS related to AMI [AMI-CS]). Methods: We examined in-hospital and 1-year outcomes of 520 (219 AMI-CS, 301 HF-CS) consecutive patients with CS (January 3, 2017–December 31, 2019) in a single-center registry. Results: Mean age was 61.5±13.5 years, 71% were male, 22% were Black patients, and 63% had chronic kidney disease. The HF-CS cohort was younger (58.5 versus 65.6 years, P <0.001), had fewer cardiac arrests (15.9% versus 35.2%, P <0.001), less vasopressor utilization (61.8% versus 82.2%, P <0.001), higher pulmonary artery pulsatility index (2.14 versus 1.51, P <0.01), lower cardiac power output (0.64 versus 0.77 W, P <0.01) and higher pulmonary capillary wedge pressure (25.4 versus 22.2 mm Hg, P <0.001) than patients with AMI-CS. Patients with HF-CS received less temporary mechanical circulatory support (34.9% versus 76.3% P <0.001) and experienced lower rates of major bleeding (17.3% versus 26.0%, P= 0.02) and in-hospital mortality (23.9% versus 39.3%, P <0.001). Postdischarge, 133 AMI-CS and 229 patients with HF-CS experienced similar rates of 30-day readmission (19.5% versus 24.5%, P =0.30) and major adverse cardiac and cerebrovascular events (23.3% versus 28.8%, P =0.45). Patients with HF-CS had lower 1-year mortality (n=123, 42.6%) compared to the patients with AMI-CS (n=110, 52.9%, P =0.03). Cumulative 1-year mortality was also lower in patients with HF-CS (log-rank test, P =0.04). Conclusions: Patients with HF-CS were younger, and despite lower cardiac power output and higher pulmonary capillary wedge pressure, less likely to receive vasopressors or temporary mechanical circulatory support. Although patients with HF-CS had lower in-hospital and 1-year mortality, both cohorts experienced similarly high rates of postdischarge major adverse cardiovascular and cerebrovascular events and 30-day readmission, highlighting that both cohorts warrant careful long-term follow-up. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03378739.

Differences between cardiogenic shock related to acute decompensated heart failure and acute myocardial infarction

“…Notably, the in‐hospital mortality of patients with heart failure related CS in our cohort (i.e. 43.8%) was significantly higher than that reported in recent large north‐American registries (ranging between 24% and 35%) 7,15 and similar to that of AMI‐CS patients' group. However, our data are in line with a recent European multicentre study on ADHF‐CS 16 .…”

“…In contrast to recently published experiences derived mainly from North American countries, 3,22,23 the use of pulmonary artery catheter was infrequent in our cohort (less than one‐fifth of the patients) in favour of a clinical and echocardiography monitoring. Furthermore, a larger adoption of MCS was registered in our cohort of ADHF‐CS patients: 42% of ADHF‐CS patients were implanted with an IABP when compared with 11.3% of the ADHF‐CS group of the recently published paper by Sinha et al 7 . The chronically elevated systemic vascular resistances of heart failure patients may benefit from treatments aiming to reduce the afterload and improving the ventriculo‐arterial coupling.…”

“…The epidemiology of CS has changed over the last few years with decreases of cases related to acute myocardial infarction (AMI‐CS ~30%) and a rise of non‐ischaemic aetiologies 4–6 . However, the majority of available evidence regarding patients' characterizations, diagnostic and therapeutic management is historically based on AMI‐CS, while very little is known about acute decompensated heart failure‐related CS (ADHF‐CS) 7,8 . The definition of ADHF‐CS pathophysiology, underlying mechanisms, and patients' phenotypes, is of utmost importance to define ad hoc diagnostic and therapeutic pathways.…”

Early Recognition and Risk Stratification in Cardiogenic Shock: Well Begun Is Half Done

“…Traditionally, acute coronary syndrome (ACS) has been the leading cause of CS, accounting for approximately 80% of cases [ 8 ]. However, recent observational studies report a declining incidence of ACS-CS, ranging from 30 to 55.4% [ 6 , 7 , 9 , 10 ], with a concurrent increase in the incidence of CS of other etiologies, mainly decompensated heart failure (AHF-CS). With the advent of the early revascularization strategy [ 11 , 12 ] established by the SHOCK trial [ 11 ], mortality rates significantly decreased from 80% [ 13 ] to 40–50% [ 14 ] in the late 1990s and early 2000s.…”

Cardiogenic shock etiology and exit strategy impact survival in patients with Impella 5.5

“…While unified by the presence of CS, patients with CS have distinctly different pathophysiology and comorbidities that impact their presentation, progression, and outcomes. 1,2 In-hospital mortality remains as high as 50% for all CS patients, but historically AMI patients have fared worse in this category. 2,3 Temporary mechanical circulatory support (tMCS) has been increasingly utilized in conjunction with inotropic and vasopressor support for management of patients in CS.…”