Elsevier

Resuscitation

Volume 155, October 2020, Pages 55-64
Resuscitation

Clinical paper
Cardiogenic shock and cardiac arrest complicating ST-segment elevation myocardial infarction in the United States, 2000–2017

https://doi.org/10.1016/j.resuscitation.2020.07.022Get rights and content

Abstract

Background

There are limited data on the outcomes of cardiogenic shock (CS) and cardiac arrest (CA) complicating ST-segment-elevation myocardial infarction (STEMI).

Methods

Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample (2000–2017) and classified as CS + CA, CS only, CA only and no CS/CA. Outcomes of interest included temporal trends, in-hospital mortality, hospitalization costs, use of do-not-resuscitate (DNR) status and palliative care referrals across the four cohorts.

Results

Of the 4,320,117 STEMI admissions, CS, CA and both were noted in 5.8%, 6.2% and 2.7%, respectively. In 2017, compared to 2000, there was an increase in CA (adjusted odds ratio [aOR] 1.83 [95% confidence interval {CI} 1.79–1.86]), CS (aOR 3.92 [95% CI 3.84–4.01]) and both (aOR 4.09 [95% CI 3.94–4.24]) (all p < 0.001). The CS+CA (77.2%) cohort had higher rates of multiorgan failure than CS only (59.7%) and CA only (26.3%), p < 0.001. The CA only cohort had lower rates (64%) of coronary angiography compared to the other groups (>70%), p < 0.001. In-hospital mortality was higher in CS+CA compared to CS alone (adjusted OR 1.87 [95% CI 1.83–1.91]), CA alone (adjusted OR 1.99 [95% CI 1.95–2.03]) or neither (aOR 18.37 [95% CI 18.02–18.71]). The CS+CA cohort had higher use of palliative care and DNR status. The presence of CS, either alone or in combination with CA, was associated with higher hospitalization costs.

Conclusions

The combination of CS and CA was associated with higher rates of non-cardiac organ failure and in-hospital mortality in STEMI compared to those with either CS or CA alone.

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.

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