Clinical paperCardiogenic shock and cardiac arrest complicating ST-segment elevation myocardial infarction in the United States, 2000–2017
Introduction
Over the last two decades, there have been significant improvements in the care of patients admitted with ST-segment elevation myocardial infarction (STEMI).1 With the advent of primary percutaneous coronary intervention (PCI), potent anti-platelet agents and guideline-directed medical therapy for primary and secondary prevention, the in-hospital mortality from STEMI is <5% in the modern era.1 About 5-10% of all STEMI patients have concomitant cardiogenic shock (CS) or cardiac arrest (CA), both of which continue to be associated with 30-50% in-hospital mortality.2, 3, 4, 5, 6, 7 Traditionally these two conditions have been studied in isolation, although nearly 30% of all CS patients have concomitant CA and vice-versa, implying substantial overlap between these conditions.8 The recent statement on the classification of CS from the Society of Cardiovascular Angiography and Intervention emphasizes the role of an ‘arrest-modifier’ at every CS stage, suggesting that concomitant CA imposes an additional risk regardless of CS severity.9 Smaller studies of STEMI patients have shown that the overlap of CS with CA is associated with poor in-hospital outcomes.8 However, there is a paucity of contemporary data in STEMI patients on the epidemiology, interaction and outcomes of CS and CA.3, 8 Acute myocardial infarction, specifically STEMI, continues to be the leading cause of CS and a major cause of CA in the modern era, and therefore it is crucial to define the epidemiology and outcomes of CS and CA in STEMI.5, 10
Using a nationally-representative population, we sought to assess the in-hospital mortality, resource utilization and temporal trends of CA and CS complicating STEMI. We hypothesized that the combination of CA and CS was associated with higher in-hospital mortality than either entity alone. We also hypothesized that there was a temporal decrease in in-hospital mortality across all categories given the improvements in acute care cardiology.
Section snippets
Study population, variables and outcomes
The National (Nationwide) Inpatient Sample (NIS) is the largest all-payer database of hospital inpatient stays in the United States. NIS contains discharge data from a 20% stratified sample of community hospitals and is a part of the Healthcare Quality and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality.11 Information regarding each discharge includes patient demographics, primary payer, hospital characteristics, principal diagnosis, up to 24 secondary
Results
In the period from January 1, 2000 to December 31, 2017, there were 4,320,117 admissions with a primary STEMI diagnosis, of which CS, CA and both were noted in 250,207 (5.8%), 268,764 (6.2%) and 118,618 (2.7%), respectively. The four cohorts had relatively comparable age and race distribution (Table 1). The CS + CA, CS only and CA only cohorts had higher comorbidity, were admitted more frequently on weekends, and were admitted more frequently to urban hospitals (Table 1). The presence of CS,
Discussion
Among hospitalized STEMI admissions in the United States between 2000 and 2017, either CA or CS was present in 15% of all admissions, and CS and CA co-existed in nearly 3% of admissions (accounting for more than 25% of all CA and CS admissions). There has been an increase in the prevalence of the combination of CS + CA over time, primarily reflecting an increase in CS complicating STEMI. The presence of either CS or CA was associated with worse outcomes than STEMI alone, and the combination of
Conclusions
CS, CA, and their combination complicate about 15% of all STEMI admissions and are associated with significantly higher in-hospital mortality. The combination of CS and CA accounts for more than one-fourth of all admissions with either CS or CA and is associated with higher rates of acute non-cardiac organ failure and in-hospital mortality. Further dedicated research into the interaction of CS and CA is crucial to improve the outcomes of this vulnerable population.
Author contributions
Study design, literature review, statistical analysis: SV, SMD, AP, LRS, KK, NDS, JCJ. Data management, data analysis, drafting manuscript: SV, SMD, AP, LRS, KK, NDS, JCJ. Access to data: SV, SMD, AP, LRS, KK, NDS, JCJ. Manuscript revision, intellectual revisions, mentorship: SMD, AP, LRS, KK, NDS, JCJ. Final approval: SV, SMD, AP, LRS, KK, NDS, JCJ.
Sources of funding
Dr. Saraschandra Vallabhajosyula is supported by the Clinical and Translational Science Award (CTSA) Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.
Conflict of interest
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
References (52)
- et al.
Temporal trends and outcomes of prolonged invasive mechanical ventilation and tracheostomy use in acute myocardial infarction with cardiogenic shock in the United States
Int J Cardiol.
(2019) - et al.
Acute noncardiac organ failure in acute myocardial infarction with cardiogenic shock
J Am Coll Cardiol.
(2019) - et al.
Clinical characteristics and outcomes of STEMI patients with cardiogenic shock and cardiac arrest
JACC Cardiovasc Interv.
(2020) - et al.
Early vs. delayed in-hospital cardiac arrest complicating ST-elevation myocardial infarction receiving primary percutaneous coronary intervention
Resuscitation.
(2020) - et al.
Evaluation of care and surveillance of cardiovascular disease: can we trust medico-administrative hospital data?
Can J Cardiol.
(2012) - et al.
Administrative billing codes for identifying patients with cardiac arrest
J Am Coll Cardiol.
(2019) - et al.
Cardiogenic shock in takotsubo cardiomyopathy versus acute myocardial infarction: an 8-year national perspective on clinical characteristics, management, and outcomes
JACC Heart Fail.
(2019) - et al.
Epidemiology of in-hospital cardiac arrest complicating non-ST-segment elevation myocardial infarction receiving early coronary angiography
Am Heart J.
(2020) - et al.
Hospital-level disparities in the outcomes of acute myocardial infarction with cardiogenic shock
Am J Cardiol.
(2019) - et al.
Management of refractory vasodilatory shock
Chest.
(2018)