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Published on: June 12, 2021
Outcomes Associated With Peripheral Artery Disease in Myocardial Infarction With Cardiogenic Shock
Nino Mihatov1, Ramya C Mosarla2, Ajay J Kirtane3
1Division of Cardiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA; Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
Insights
Patients with peripheral artery disease (PAD) and acute myocardial infarction (AMI) with cardiogenic shock (CS) face higher mortality and limb complication risks. Lower use of mechanical circulatory support (MCS) in PAD patients correlated with worse outcomes.
Area of Science:
- Cardiology
- Vascular Surgery
- Critical Care Medicine
Background:
- Mortality rates for acute myocardial infarction (AMI) with cardiogenic shock (CS) remain high despite advanced treatments.
- Mechanical circulatory support (MCS) and revascularization strategies have improved care, but outcomes are still concerning.
Purpose of the Study:
- To investigate the association between comorbid peripheral artery disease (PAD) and patient outcomes in acute myocardial infarction (AMI) with cardiogenic shock (CS).
- To analyze the impact of PAD on mortality, limb complications, and treatment utilization in CS and AMI patients.
Main Methods:
- Retrospective analysis of Medicare beneficiaries hospitalized with CS and AMI between October 2015 and June 2018.
- Outcomes including in-hospital and out-of-hospital mortality, amputation, bleeding, stroke, and revascularization were assessed.
- Multivariable regression models and subgroup analyses (MCS, coronary revascularization) were used to determine risk associations.
Main Results:
- Peripheral artery disease (PAD) was present in 5.9% of 71,690 patients and was associated with significantly higher in-hospital (56.3% vs. 46.6%) and out-of-hospital mortality.
- PAD patients had a substantially increased risk of in-hospital amputation (OR: 7.0) and lower extremity revascularization.
- Mechanical circulatory support (MCS) was underutilized in PAD patients (21.5% vs. 38.6%) and associated with worse outcomes when used.
Conclusions:
- Peripheral artery disease (PAD) is linked to poorer survival and limb outcomes in patients with acute myocardial infarction (AMI) and cardiogenic shock (CS).
- Lower rates of mechanical circulatory support (MCS) utilization in PAD patients, coupled with increased mortality and amputation risks upon MCS use, highlight critical care disparities.
Background:
Mortality rates for patients presenting with acute myocardial infarction (AMI) and cardiogenic shock (CS) remain high despite advances in revascularization strategies and mechanical circulatory support (MCS) devices.
Objectives:
This study sought to elucidate the association between comorbid lower extremity peripheral artery disease (PAD) and outcomes in CS and AMI.
Methods:
PAD status was defined in Medicare beneficiaries hospitalized with CS and AMI from October 1, 2015 to June 30, 2018. Primary outcomes ascertained through December 31, 2018 included in- and out-of-hospital mortality. Secondary outcomes included bleeding, amputation, stroke, and lower extremity revascularization. Multivariable regression models with adjustment for confounders were used to estimate risk. Subgroup analyses included patients treated with MCS and those who underwent coronary revascularization.
Results:
Among 71,690 patients, 5.9% (N = 4,259) had PAD. Mean age was 77.8 ± 7.9 years, 58.7% were male, and 84.3% were White. Cumulative in-hospital mortality was 47.2%, with greater risk among those with PAD (56.3% vs 46.6% without PAD; adjusted OR: 1.50; 95% CI: 1.40-1.59). PAD patients also had greater risk of in-hospital amputation (1.6% vs 0.2%; adjusted OR: 7.0; 95% CI: 5.26-9.37) and out-of-hospital mortality (67.9% vs 40.7%; adjusted HR: 1.78; 95% CI: 1.67-1.90). MCS was less frequently utilized in PAD patients (21.5% vs 38.6% without PAD; P < 0.001) and was associated with higher mortality, need for lower extremity revascularization, and amputation risk. Findings were consistent in patients who underwent coronary revascularization.
Conclusions:
Among patients presenting with AMI and CS, PAD was associated with worse limb outcomes and survival. In addition to lower MCS utilization rates, those with PAD who received MCS had increased mortality, lower extremity revascularization, and amputation rates.
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