Implementation of a Comprehensive ST-Elevation Myocardial Infarction Protocol Improves Mortality Among Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock

Abstract

Mortality in patients with STEMI-associated cardiogenic shock (CS) is increasing. Whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) can improve their care delivery and mortality is unknown. We evaluated the impact of a CSP on incidence and outcomes in patients with STEMI-associated CS. We implemented a 4-step CSP including: (1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). We studied 1,272 consecutive STEMI patients who underwent PCI and assessed for CS incidence per National Cardiovascular Data Registry definitions within 24-hours of PCI, care delivery, and mortality before (January 1, 2011, to July 14, 2014; n = 723) and after (July 15, 2014, to December 31, 2016; n = 549) CSP implementation. Following CSP implementation, CS incidence was reduced (13.0% vs 7.8%, p = 0.003). Of 137 CS patients, 43 (31.4%) were in the CSP group. CSP patients had greater IABP-Shock II risk scores (1.9 § 1.8 vs 2.8 § 2.2, p = 0.014) with otherwise similar hemodynamic and baseline characteristics, cardiac arrest incidence, and mechanical circulatory support use. Administration of guideline-directed medical therapy was similar (89.4% vs 97.7%, p = 0.172) with significant improvements in trans-radial PCI (9.6% vs 44.2%, p < 0.001) and door-to-balloon time (129.0 [89:160] vs 95.0 [81:116] minutes, p = 0.001) in the CSP group, translating to improvements in infarct size (CK-MB 220.9 § 156.0 vs 151.5 § 98.5 ng/ml, p = 0.005), ejection fraction (40.8 § 14.5% vs 46.7 § 14.6%, p = 0.037), and in-hospital mortality (30.9% vs 14.0%, p = 0.037). In conclusion, CSP implementation was associated with improvements in CS incidence, infarct size, ejection fraction, and in-hospital mortality in patients with STEMI-associated CS. This strategy offers a potential solution to bridging the historically elusive gap in their care.

Prognostic implications and outcomes of cardiac arrest among contemporary patients with STEMI treated with PCI

“…It remains unknown if implementation of a system of care which standardizes guideline-directed medical therapy, improves door-to-balloon times, and promotes revascularization and access to mechanical circulatory support could result in improvement in in-hospital mortality and thus translate to superior outcomes. 16 , 17 …”

ST Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Systematic Review of Survival Predictors

“…Regardless, comprehensive STEMI protocols which expedited revascularization timing were found to be favorable prognostically and associated with improved survival. 22 Kumar et al. identified the following 4 key aspects of a successful revascularization protocol: (1) emergency department activation of the catheterization laboratory; (2) standardized patient triage and handover; (3) transfer to an available catheterization laboratory; and (4) a “radial-first” approach.…”

“…identified the following 4 key aspects of a successful revascularization protocol: (1) emergency department activation of the catheterization laboratory; (2) standardized patient triage and handover; (3) transfer to an available catheterization laboratory; and (4) a “radial-first” approach. 22 …”

Sex differences in the presentation and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock: a critical review of contemporary data and a look towards future directions

“…For this reason, implementation of clear protocols for care can lead to improved equity in care across the populations we serve. This is supported by studies which showed improved times to treatments in AMI, and improved outcomes for patients with AMI-CS with the institution of protocols for care [58–60] with elimination (or narrowing) of sex based disparities in care [24 ▪ ,33 ▪▪ ,4]. For example, the placement of MCS before PCI is associated with greater survival in women and men with AMI-CS [44], and some studies have shown that when MCS is instituted early in AMI-CS (prior to PCI), women derive a greater benefit then men [31 ▪ ,35 ▪ ].…”