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Cardiovascular Disease

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Henry Ford Hospital


BACKGROUND: Acute myocardial infarction cardiogenic shock (AMICS) continues to carry high morbidity and mortality, despite advances in revascularization strategies. Recent data shows several trends in the field of AMICS, including increased patient complexity, overall low utilization of percutaneous mechanical circulatory support (MCS), and increased mortality rates. We sought to study the clinical characteristics and outcomes of AMICS patients at our institution. METHODS: From January 2014 to June, 2017, consecutive patients admitted to Henry Ford Hospital’s Cardiac Intensive Care Unit with a primary diagnosis of cardiogenic shock in the setting of ST elevation or non-ST elevation myocardial infarction were identified and retrospectively studied. Cardiogenic shock diagnosis was confirmed in accordance with definition in the SHOCK trial. Comprehensive baseline characteristics and clinical outcomes were reviewed. RESULTS: A total of 120 patients were included. Mean age was 66 ± 12 years; 80 (67%) were males and 60 (50%) were Caucasian. Prior history of congestive heart failure was present in 19% of patients, prior CABG in 10% and prior PCI in 18% of the cardiogenic shock population. 83 (69%) of the patients presented with STEMI and 37 (31%) patients with NSTEMI. Cardiac arrest on admission occurred in 27 (22.5%) of patients and average hospital length of stay was 10.5 ± 10.3 days. Percutaneous MCS was used in 110 (92%) of patients: IABP = 65; Impella = 31; upgrade from IABP to other advanced MCS = 14. Last vital signs and perfusion parameters immediately before MCS placement, often while on vasopressors, were as follows: mean systolic BP 91 ± 18.3 mmHg, mean diastolic BP 69 ± 19 mmHg, mean HR 91.8 ± 18.3 bpm, mean creatinine level 1.85 ± 1.2, mean AST level 546 ± 977 and mean lactate level 4.0 ± 3.3. The in-hospital survival of the entire AMICS population was 41%. There was a statistically significant difference in survival between patients admitted from within the native health system (N=45; survival = 55.6%) and transfer patients from outside referring institutions (N=75; survival = 34.7%), p = 0.0310. Survival among the 10 patients with AMICS treated with vasopressors only was 10%. Successful revascularization was performed in 90 (75%) of patients. Only 3 (10%) of the non-revascularized patients survived to hospital discharge. Among successfully revascularized patients, the overall in-hospital survival was 50%.CONCLUSIONS: In this real-world experience, we find that AMICS continues to carry high overall mortality. The frequent use of percutaneous MCS demonstrates feasibility of providing hemodynamic support; however, timing of MCS initiation was not standardized and often was delayed until significant signs of hypoperfusion have ensued. Hence, there is now a shift towards a standardized strategy of early initiation of mechanical support and revascularization which may help improve outcomes of AMICS patients.

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Clinical Outcomes of Acute Myocardial Infarction Cardiogenic Shock: A Contemporary Single Center Experience