Temporal trends in clinical presentation, infarction characteristics and outcome in patients with ST-elevation myocardial infarction complicated by cardiogenic shock

Introduction: Patients (pts) with ST-elevation myocardial infarctions (STEMI) complicated by cardiogenic shock (CS) remain at very high risk despite recent advances in therapeutic strategies. Aim of the present study was to analyse prevalence rates, predictors and outcome in pts with STEMI complicated by CS admitted to a large primary percutaneous coronary intervention (PCI) center in Germany.

Methods: All pts admitted between 2006 and March 2022 were included for baseline analysis.  Pts with an index event between January 2006 and December 2020 were assessed for follow up evaluation.

Results: Out of a total of 12089 pts with STEMI 1830 (15%) presented with CS. Mean age was of 65.7±13 years and 28% were female. The total number and proportion of CS doubled during the study period: 2006-2007: 80 patients with CS/year (10.2% of total) to 2020-21: 162 patients with CS/year, (20.1% of total). Over time, pts with CS were significant less likely to present with typical chest pain (2006-07: 83.5% to 2020-22: 58.3%, p<0.01). Corresponding to that, the rate of syncope at presentation significantly increased (2006-07: 19.5% to 2020-22: 39.6%, p<0.01). Rates of primary percutaneous coronary interventions (PCI) in CS increased from 2006-2007: 75.1% to 2020-22: 90.0%, p<0.01 with on average more stents implanted: 2006-2007: n=1.3±0.6 to 2020-2022: n=1.8±1.0 and significantly higher rates of successful PCI (TIMI-3-flow) 2006-07: 75.8% to 2020-22: 90.4%, p<0.01. In CS lack of initial typical chest pain was associated with higher overall 1-year mortality (60.5%. vs. 45.0%, p<0.01), while successful PCI was associated with lower mortality-rates (44.3% to 71.6%, p<0.01). During the study period mortality rates for the entire CS-cohort remained high (1-year-mortality: 2006-08: 54.8% vs. 2018-20: 54.9%). However, when excluding CS-pts with atypical presentation a significant decrease in 30-day and 1-year-mortality rates over time could be shown as well as a decrease in 1-year adverse ischemic event rates* (table).

 

	2006-2008	2009-2011	2012-2014	2015-2017	2018-2020	P (for trend)
30-day mortality (%)	42.5	43.6	35.4	27.7	34.3	0.011
1-year mortality (%)	50.0	45.9	38.8	34.4	41.2	0.026
1-year-adverse ischemic event rates* (%)	8.9	2.4	0.7	3.7	2.6	0.059

table: temporal trends in adverse event rates in pts with STEMI and CS
*composite of reinfarction, stent thrombosis, repeat target leasion or target vascular revascularisation

Conclusions: During the observation period the proportion of STEMI-pts presenting with CS increased significantly with a higher likelihood of atypical symptoms. According to recent guideline recommendations rates of attempted and successful PCI are significantly higher nowadays.

While overall 30 day and 1year mortality rates remained high for the entire CS-cohort, CS-pts initially presenting with typical chest pain undergoing successful PCI showed a more than 20% decrease in 30-day and 1-year-mortality during the study period.

These findings underline first the growing share of CS in pts with STEMI and secondly the importance of a timely and successful PCI in these pts.