Prognostic Significance of a Combination of Cardiogenic Shock and the Critical Culprit Lesion Location in ST-Elevation Myocardial Infarctions

Abstract

Both cardiogenic shock (CS) and critical culprit lesion locations (CCLLs), defined as the left main trunk and proximal left anterior descending coronary artery, are associated with worse outcomes in ST-elevation myocardial infarctions (STEMIs). We aimed to examine how the combination of CS and/or CCLLs affected the prognosis in Japanese STEMI patients in the primary percutaneous coronary intervention era (PPCI-era). The subjects included 624 STEMI patients admitted to our hospital between January 2013 and April 2020. They were divided into four groups according to the combination of CS and CCLLs: CS (−) CCLL (−) group [n = 405], CS (−) CCLL (+) group [n = 150], CS (+) CCLL (−) group [n = 25], and CS (+) CCLL (+) group [n = 44].The cumulative incidences of all-cause death at 30 days and 1 year were 3.5% and 6.4% in the CS (−) CCLL (−), 3.3% and 5.6% in the CS (−) CCLL (+), 32.0% and 32.0% in the CS (+) CCLL (−), and 50.0% and 65.9% in the CS (+) CCLL (+) group, respectively. After a multivariate adjustment, the CS (+) CCLL (+) group was independently associated with all-cause death (hazard ratio: 17.00, 95% confidence interval: 7.12-40.59 versus the CS (−) CCLL (−) group). In the CS (+) CCLL (+) group, compared to years 2013-2017, the IMPELLA begun to be used (44.4% versus 0%), and intra-aortic balloon pumps significantly decreased (44.4% versus 92.3%) during years 2018-2020, while the medications upon discharge did not significantly differ. The 30-day mortality was numerically lower during years 2018-2020 than years 2013-2017 (Log-rank test, P = 0.092). In conclusion, the prognosis of STEMIs varies greatly depending on the combination of CS and CCLLs, and in particular, patients with both CS and CCLLs had the poorest prognosis during the modern PPCI-era.

Inotropic support in cardiogenic shock: who leads the battle, milrinone or dobutamine?

“…However, it should be noted that if during shock there is a decrease in cardiac output but maintenance of peripheral vascular resistance, Dobutamine can regulate blood pressure and hemodynamics without problem. However, if the decrease in peripheral vascular resistance is severe and the increase in cardiac output is not proportional, a state of persistent hypotension with vasodilatory shock may occur [ [25] , [26] , [27] ]. Considering the half-life of Dobutamine (<2 min), this agent achieves a rapid compensation of cardiac output in patients with post-infarction shock, which is favorable even in cases requiring rapid stabilization for transfer to specialized management.…”