Differences Between STEMI and NSTEMI Complicated by Cardiogenic Shock: Insights From a Contemporary Multilevel
Serdar Farhan1, Sanjay Sivalokanathan2, Abduljabar Adi1
1Northwell Health, Cardiovascular Institute, New Hyde Park, New York, USA; Lenox Hill Hospital at Northwell Health, New York, New York, USA.
Insights
Patients with cardiogenic shock (CS) from ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) have different profiles but similar mortality. Management strategies and mechanical support outcomes vary by AMI type.
Area of Science:
- Cardiology
- Intensive Care Medicine
- Acute Myocardial Infarction Research
Background:
- Understanding clinical trajectories in cardiogenic shock (CS) based on acute myocardial infarction (AMI) type is crucial for contemporary practice.
- Contemporary management of CS requires nuanced approaches tailored to specific AMI phenotypes.
Purpose of the Study:
- To compare clinical characteristics, management strategies, and outcomes of patients experiencing CS due to ST-segment elevation myocardial infarction (STEMI) versus non-ST-segment elevation myocardial infarction (NSTEMI).
- To identify differences in patient profiles, treatment interventions, and mortality rates between STEMI-CS and NSTEMI-CS cohorts.
Main Methods:
- Retrospective analysis of adult patients treated for CS due to STEMI or NSTEMI within an 11-hospital health system (2016-2022).
- Primary outcome: 6-month all-cause mortality; Secondary outcome: in-hospital all-cause mortality.
- Comparison of demographic data, comorbidities, shock severity markers (lactate, cardiac arrest), revascularization strategies (PCI, CABG), and mechanical circulatory support (IABP, PVAD, VA-ECMO).
Main Results:
- 1,375 patients identified: 57% STEMI-CS and 43% NSTEMI-CS.
- STEMI-CS patients presented with more severe shock (cardiac arrest, higher lactate); NSTEMI-CS patients were older with more comorbidities and severe coronary disease.
- In-hospital and 6-month mortality rates were similar (approx. 37% vs 34%, P=0.53). Revascularization improved survival; IABP/PVAD benefited STEMI-CS only. VA-ECMO was associated with increased mortality in both groups.
Conclusions:
- STEMI-CS and NSTEMI-CS patients exhibit distinct clinical profiles and receive different management strategies, including revascularization approaches.
- Despite similar overall mortality, the impact of mechanical circulatory support varies significantly between STEMI-CS and NSTEMI-CS phenotypes.
- AMI type is a critical factor that should guide clinical management decisions and future research design for patients with cardiogenic shock.
Background:
An enhanced understanding is needed of the clinical trajectories seen in contemporary practice among patients with cardiogenic shock (CS) due to different acute myocardial infarction (AMI) types.
Objectives:
The objective of the study was to compare clinical characteristics, management strategies, and outcomes among patients with CS due to AMI with and without ST-segment elevation.
Methods:
All adults treated for CS due to STEMI or NSTEMI within a multilevel of care health system spanning 11 hospitals from 2016 to 2022 were included. The primary and secondary outcomes were 6-month and in-hospital all-cause mortality.
Results:
We identified 1,375 patients: 57% ST-segment elevation myocardial infarction with CS (STEMI-CS) and 43% non-STEMI-CS (NSTEMI-CS). STEMI-CS patients had more severe shock with more cardiac arrest and higher initial lactate whereas NSTEMI-CS patients were older with more comorbidities and more severe coronary disease. NSTEMI-CS patients received more coronary artery bypass grafting (33% vs 8%) and lower rates of percutaneous coronary intervention (35% vs 73%) in those undergoing left heart catheterization. Management patterns were consistent across hospital levels. Rates of in-hospital and 6-month mortality (STEMI-CS 37.1% vs NSTEMI-CS 34.0%; P = 0.53) were similar in both groups. On multivariable analysis, revascularization was associated with lower 6-month mortality in both groups, whereas intra-aortic balloon pump or percutaneous ventricular assist device use was associated with lower mortality only in STEMI-CS. Venoarterial extracorporeal membrane oxygenation was associated with increased mortality in both AMI types.
Conclusions:
STEMI and NSTEMI patients with CS have distinct clinical profiles and management strategies across all hospital levels. Although they experience similar rates of short and long-term mortality, associations between mechanical circulatory support use and outcomes differ by phenotype. These findings suggest that AMI type should inform management strategies and research design in CS.
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