Differences between cardiogenic shock related to acute decompensated heart failure and acute myocardial infarction

Abstract

AimsThe present analysis from the multicentre prospective Altshock‐2 registry aims to better define clinical features, in‐hospital course, and management of cardiogenic shock complicating acutely decompensated heart failure (ADHF‐CS) as compared with that complicating acute myocardial infarction (AMI‐CS).Methods and resultsAll patients with AMI‐CS or ADHF‐CS enrolled in the Altshock‐2 registry between March 2020 and February 2022 were selected. The primary objective was the characterization of ADHF‐CS patients as compared with AMI‐CS. In‐hospital length of stay and mortality were secondary endpoints. One‐hundred‐ninety of the 238 CS patients enrolled in the aforementioned period were considered for the present analysis: 101 AMI‐CS (80% ST‐elevated myocardial infarction and 20% non‐ST‐elevated myocardial infarction) and 89 ADHF‐CS. As compared with AMI‐CS, ADHF‐CS patients were younger [63 (IQR 59–76) vs. 67 (IQR 54–73) years, P = 0.01], but presented with higher creatinine [1.6 (IQR 1.0–2.6) vs. 1.2 (IQR 1.0–1.4) mg/dL, P < 0.001], bilirubin [1.3 (IQR 0.9–2.3) vs. 0.6 (IQR 0.4–1.1) mg/dL, P = 0.01], and central venous pressure values [14 mmHg (IQR 8–12) vs. 10 mmHg (IQR 7–14),P = 0.01]. Norepinephrine was the most common catecholamine used in AMI‐CS (79.3%), whereas epinephrine was used more commonly in ADHF‐CS (65.5%); 75.8% vs. 46.6% received a temporary mechanical support in AMI‐CS and ADHF‐CS, respectively (P < 0.001). Length of hospital stay was longer in the latter [28 (IQR 13–48) vs. 17 (IQR 9–29) days, P = 0.001]. Heart replacement therapies were more frequently used in the ADHF‐CS group (heart transplantation 13.5% vs. 0% and left ventricular assist device 11% vs. 2%, P < 0.01 and 0.01, respectively). In‐hospital mortality was 41.1% (38.6% AMI‐CS vs. 43.8% ADHF‐CS, P = 0.5).ConclusionsADHF‐CS is characterized by a higher prevalence of end‐organ and biventricular dysfunction at presentation, a longer hospital length of stay, and higher need of heart replacement therapies when compared with AMI‐CS. In‐hospital mortality was similar between the two aetiologies. Our data warrant development of new management protocols focused on CS aetiology.

In‐hospital and long‐term outcomes of cardiogenic shock complicating myocardial infarction versus heart failure

“…4 Prospective data from a registry in Italy revealed that HF-CS often presents with more complex clinical features, including a higher prevalence of end-organ and biventricular dysfunction, a longer hospital stay, and a greater necessity for heart replacement therapies compared to AMI-CS. 25 While this study reported a numerically higher in-hospital mortality rate for HF-CS, the difference was not statistically significant. These findings, which contrast with some US-based studies, underscore the variability in HF-CS manifestations and outcomes across different healthcare settings.…”

“…Similarly, in the CCCTN registry, AMI‐CS was associated with higher cardiac ICU and in‐hospital mortality than CS without AMI 4 . Prospective data from a registry in Italy revealed that HF‐CS often presents with more complex clinical features, including a higher prevalence of end‐organ and biventricular dysfunction, a longer hospital stay, and a greater necessity for heart replacement therapies compared to AMI‐CS 25 . While this study reported a numerically higher in‐hospital mortality rate for HF‐CS, the difference was not statistically significant.…”

Medical therapy of cardiogenic shock: Contemporary use of inotropes and vasopressors

“…135 The choice of inotropes/vasopressors may also be affected by the aetiology of CS (Figure 2). 136 AMI-CS was associated with significantly lower SVR and a trend towards higher cardiac index compared to ADHF-CS. 137 Such low SVR may be related to systemic inflammation in relation to myocardial necrosis triggered by interleukins, tumour necrosis factor-α and inducible NO synthase.…”

Inotropic Agents: Are We Still in the Middle of Nowhere?

“…Similarly, Lim et al demonstrated that patients experiencing HF-CS exhibit a distinct phenotype compared with those with acute myocardial infarction (AMI), characterized by elevated filling and pulmonary artery pressures [65]. Ongoing, Bertaina M et al concluded that a higher congestive profile (higher CVP at index evaluation) and worsened biventricular dysfunction [66] appear more characterizing patients with CS-HF than patients with CS from AMI. Together, these findings advocate for strategies to enhance cardiac output while mitigating factors that could elevate pulmonary resistance in patients with chronic HF.…”