Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

Abstract

BackgroundDespite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated.MethodsWe analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality.ResultsAmong 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, P < 0.01). Considering data available at FMC, CS patients with a combination of age ≥76 years, anterior STEMI and an expected ischemia time > 3 h and 21 min were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045–1,141; P = 0.003), final TIMI flow 2–3 (OR 0.058; 95% CI 0.004–0.785; P = 0.032) and Ischemia Time (OR = 1.269; 95% CI 1.001–1.609; P = 0.049) were independently associated with 30-day mortality.ConclusionsIn a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.

Coronary artery disease: novel insights in a long-standing disease

“…2 Cardiogenic shock compared with non-cardiogenic shock patients had higher rates of 30-day mortality (33 vs. 3%, P < 0.01). 2 Killip class III-IV at presentation was an independent predictor of early and late adverse cardiovascular events. 3 Many other scores can be used as simple and useful clinical tools for risk stratification [e.g.…”

“…In a contemporary real-world population of patients presenting with STEMI, in-hospital, 30-day and long-term (median follow-up of 38 months) mortality were 5.1, 5.4 and 10.8%, respectively 2 . Cardiogenic shock compared with non-cardiogenic shock patients had higher rates of 30-day mortality (33 vs. 3%, P < 0.01) 2 . Killip class III–IV at presentation was an independent predictor of early and late adverse cardiovascular events 3 .…”

“…Mortality of patients with ACS remains high 1 . In a contemporary real-world population of patients presenting with STEMI, in-hospital, 30-day and long-term (median follow-up of 38 months) mortality were 5.1, 5.4 and 10.8%, respectively 2 . Cardiogenic shock compared with non-cardiogenic shock patients had higher rates of 30-day mortality (33 vs. 3%, P < 0.01) 2 .…”

Mortality outcomes and predictors of failed thrombolysis following STEMI thrombolysis in a non-PCI capable tertiary hospital: a 5-year analysis

“…In STEMI thrombolysis, Killip classification of II–IV during STEMI presentation is another risk factor of all-cause mortality at 30 days [ 38 ]. Similarly, significantly higher mortality at 30 days was reported among cardiogenic shock (Killip 4) STEMI patients who had undergone primary PCI [ 34 ]. In our study, the proportion of STEMI patients with Killip II-IV was higher than 12.2–29.3% reported in clinical trials related to thrombolytic agents, indicating that STEMI patients in this study were more ill during the presentation in ED [ 31 , 33 ].…”

“…Our mortality rate was worrisome as it was comparable to 6.2–10.7% as reported in the major clinical trials on thrombolytic agents before the era of DAPT plus anticoagulant, probably due to more ill patients with higher mortality risk in this study [ 30 – 33 ]. The higher STEMI in-hospital mortality in our non-PCI-capable centre, compared to less than 6% reported by the Malaysia NCVD and international studies, strongly suggests the need to establish more PCI-capable facilities in the country [ 29 , 34 ].…”