Differences Between STEMI and NSTEMI Complicated by Cardiogenic Shock: Insights From a Contemporary Multilevel...

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.

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.

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.

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.

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.