Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock

Abstract

Background Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST‐segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS‐STEMI). Objective We evaluated 10‐year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS‐STEMI. Methods We performed a retrospective cohort study of CS‐STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra‐aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation. Results Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS‐STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in‐hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in‐hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs. Conclusions Bleeding and ALI are common complications associated with CS‐STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS‐STEMI.

Complications from percutaneous-left ventricular assist devices versus intra-aortic balloon pump in acute myocardial infarction-cardiogenic shock

“…This is one of the largest studies to holistically review and discuss complications of pLVAD and IABP use in AMI-CS. Prior studies from the HCUP-NIS database have discussed individual complications specifically, but have not investigated the broad categories of clinically relevant complications that are reviewed in the present study [37,40,41]. Our results are consistent with prior work demonstrating that pLVAD has a higher overall complication rate when compared to IABP [6,20,22,23,42].…”

“…Lastly, this study showed a temporal increase in complication rates amongst both cohorts, contrary to the expected decrease in complication rates that should occur with increased operator experience over time. Given the administrative nature of the database, it is possible that these trends could be a function of systematic changes in coding over time similar to other literature published on this topic from the HCUP-NIS database [40,41]. Further investigation is needed to determine patient-specific factors that may better delineate optimal candidates for pLVAD versus IABP and adherence to guideline-directed use of these MCS devices.…”

The science of safety: complications associated with the use of mechanical circulatory support in cardiogenic shock and best practices to maximize safety

“…Similarly, bleeding occurred in 19.4%, 29.9%, and 54.2% of each group, respectively, while limb ischemia occurred in 0.9%, 3.6%, and 7.7%, respectively. All of these complications were associated with increased length of stay and hospitalization costs 22 , 23 . While it stands to reason that more invasive devices would lead to higher complication rates, it must be noted that these observational studies do not account for significant baseline differences between the real-world patients in whom the devices are deployed.…”

Acute myocardial infarction related cardiogenic shock: How important is vascular access site?

“…So, in this relatively small study, lower rates of bleeding observed with radial access did not translate into improved survival. Similarly, others have shown that acute bleeding in CS patients was not associated with higher mortality, once one controlled for the higher baseline risk in patients who bled 3,4 . This suggests that mortality in CS patients is primarily related to factors other than bleeding (such as multiorgan failure, anoxic encephalopathy, progressive heart failure), unless of course, serious bleeding occurs.…”