https://doi.org/10.1007/s00392-025-02625-4
1Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; 2Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland; 3Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 4Universitätsklinikum Köln Herzzentrum - Kardiologie Köln, Deutschland; 5Krankenhaus der Augustinerinnen, Akademisches Lehrkrankenhaus Klinik für Kardiologie und internistische Intensivmedizin Köln, Deutschland; 6St. Antonius Krankenhaus Medizinische Klinik & Kardio-Diabetes-Zentrum Köln Köln, Deutschland; 7Ev. Krankenhaus Köln-Kalk Kardiologie & Internistische Intensivmedizin Köln, Deutschland; 8Krankenhaus Porz am Rhein gGmbH Klinik für Kardiologie, Elektrophysiologie u. Rhythmologie Köln, Deutschland; 9Cellitinnen Krankenhaus St. Vinzenz Köln Innere Medizin III - Kardiologie Köln, Deutschland; 10Kliniken der Stadt Köln gGmbH, Krankenhaus Merheim Medizinische Klinik II Köln, Deutschland; 11Klinikum Leverkusen Klinik für Akut- und Notfallmedizin Leverkusen, Deutschland; 12Universitätsklinikum Köln Klinik III für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland
Background: Cardiogenic shock (CS) is a severe complication in ST-segment elevation myocardial infarction (STEMI). CS is historically defined by the combination of hypotension and hypoperfusion. There is growing evidence that CS is a continuum and that even the presence of a single hemodynamic or perfusion deficit might indicate preliminary shock stages. Little is known on the role of so called “preshock” stages in dedicated STEMI patients.
Objective: This study examined the prevalence and outcomes of preshock stages at admission in STEMI.
Methods: The multicentric, metropolitan registry included STEMI patients registered between January 2024 and October 2024. Patients with documented hemodynamic and perfusion criteria at admission were classified. Eligible subjects were stratified by the presence or absence of perfusion and hemodynamic deficits resulting in five different clusters (see A). Preshock stages were compared to patients without evidence of shock. Data were analyzed using Chi-square test. A two-sided p-value < 0.05 was defined as statistically significant. Investigated outcomes were:
a) in-hospital mortality
b) development of sustained CS after catheterization (as judged by the treating investigator in accordance with contemporary guidelines)
c) use of mechanical circulatory support (MCS)
Results: In total, 647 patients were registered in the STEMI registry. Of these, 165 were eligible (see B). At admission, 35.8% presented with preshock, and 27.8% had signs of classic CS. Normotensive preshock was the most prevalent cluster (25.5%, see C).
In-hospital mortality was the highest among classic CS (47.8%) and hypotensive preshock (22.2%). Normotensive preshock (4.8%), hypertensive preshock (0%) and no shock (3.3%) patients had lower event rates (p<0.001 for overall comparison).
Sustained CS after catheterization was diagnosed in 12.1% of STEMI. In detail, 33.3% of hypotensive preshock and 30.8% of classic CS at admission developed sustained CS. Correspondingly, normotensive preshock (4.8%), hypertensive preshock (0%) and no shock (1.7%) patients had lower event rates (p<0.001 for overall comparison).
Overall, 19 patients (11.5%) required MCS, microaxial flow pump was used in nine patients (47.4%), while extracorporeal membrane oxygenation was established in ten patients (52.6%). MCS was established in 32.6% of classic CS and 7.1% of normotensive preshock patients. One patient with no shock pattern (1.7%) at admission required MCS during hospital stay. Neither hypertensive nor hypotensive preshock patients were treated with MCS (p<0.001 for overall comparison). The authors hypothesize, that the unexpected low MCS rate in hypotensive preshock is rather attributed to survival bias than to other factors.
Conclusion: Preshock was a prevalent finding at admission among sampled STEMI patients. Patients with classic CS pattern at admission, but also those with normotensive or hypotensive preshock had an impaired short-term prognosis. While blood pressure was frequently recorded at admission, serum lactate was not. Serum lactate is easily assessable and allows for timely recognition of hypoperfusion. These findings support routine measurement of serum lactate at admission. Moreover, prognostication of STEMI patients at admission considering preshock stages might add value, but external validation of this concept is warranted.