Abstract
Background
Cardiogenic shock (CS) is an ominous complication of ST elevation myocardial infarction (STEMI). However, the widespread use of reperfusion therapies and invasive management could have reduced the prevalence of CS and improved the prognosis of these patients in the last decades.
Purpose
The aim is to analyze the changes over last three decades in the prevalence, management and acute phase prognosis and 1-year mortality of STEMI patients complicated with CS.
Method
Between February 1989 and December 2017, 7,589 STEMI patients were consecutively admitted in the Coronary Care Unit of a University Hospital and were included in a prospective registry. Depending on the year of admission, patients were classified in five groups: 1989–1994: n=1,337, period 1; 1995–1999: n=960, period 2; 2000–2004: n=1,059, period 3; 2005–2009: n=1,535, period 4 and 2010–2015: n=2,698, period 5). We analyze the trend in prevalence of CS, management and 28-day and 1-year mortality over these five periods.
Results
The global prevalence of CS was 6.1% (466 patients), mean age was 67.7 (SD 11.7) years and 68.7% were men. Prevalence of CS in STEMI decreased from period 1 to 5 (7.3%, 6.4%, 5.5%, 5.8%, 6.0%, p<0.001), although it has been reduced more in women (10.1% in period 1 vs 8.3%, period 5, p<0.001) than in men (6.5% vs 5.4%, period 1 vs 5, respectively (p<0.001). Reperfusion therapy increased from 25.8% in period 1 (all with thrombolysis) vs 83.8% in period 5 (all with primary angioplasty). Intra-aortic balloon contrapulsation was only available from period 3 to 5, and it's used were firstly increased (20.7%, 36% and 37.9%, respectively, p<0.001). Ventricular assistance device (Impella CP) it was only available in 2017 and it was implanted in 10.5% of CS due to STEMI. Although 28-day case fatality is very high (60.7%, 283 patients), it has been reduced from period 1 to 5 (69.6%, 77.3%, 64.7%, 55.9% and 57.8%, respectively, p=0.012). This reduction in 28-day case fatality was higher in women (75.5% in period 1 vs 58.6% in period 5, p=0.12) than in men (66.8% vs 57.3, period 1–5, p=0.019). One-year mortality has been reduced between periods 1–5 (73.7% vs 61.8%, p=0.012). After multivariate adjustment, both 28-day (HR 0.63, 95% CI: 0.45–0.89, p=0.008) and 1-year mortality (HR 0.64, 95% CI: 0.45–0.90, p=0.010) have declined in the last period.
Kaplan-Meier curves, 1-year mortality
Conclusions
Cardiogenic shock development in STEMI patients has been reduced from 7.3% to 6.1% in the last three decades. The whole improvement in management of these patients achieves a 37% of reduction in 28-day case fatality and 1-year all-cause mortality. Despite this improvement, acute phase (28-day) case fatality of STEMI complicated with CS remains over 57% in the primary angioplasty era.
Angiographic risk factors of late cardiogenic shock in patients with ST elevation myocardial infarction patients treated by primary angioplasty
