Cardiogenic Shock Still Tied to High Post-PCI Mortality for ACS Patients

Patients undergoing PCI for ACS in the setting of cardiogenic shock continue to have an elevated risk of death in the first postprocedural year despite advanced contemporary care, according to a study published in the December 2014 issue of JACC: Cardiovascular Interventions.

Vijay Kunadian, MBBS, MD, of Newcastle University (Newcastle-upon-Tyne, England), and colleagues looked at data from the British Cardiovascular Intervention Society (BCIS) PCI database on 6,489 ACS patients who received an intervention in the setting of cardiogenic shock. 

Mortality rates at 30 days, 90 days, and 1 year were 37.3%, 40.0%, and 44.3%, respectively. Corresponding rates among ACS patients without shock were substantially lower at 2.0%, 2.81%, and 5.14%, respectively.

Using multivariate logistic regression, the researchers identified several factors associated with a higher likelihood of dying at 1 year among patients with cardiogenic shock (table 1). 

In contrast, lower rates of 1-year mortality were predicted by post-PCI TIMI flow grade 3 (OR 0.44; 95% CI 0.37-0.51) and use of radial access (OR 0.79; 95% CI 0.69-0.90).

More Work to Be Done 

Given the advances made in interventional and pharmacotherapeutic care of patients with STEMI, the high mortality rates observed were surprising, according to Dr. Kunadian.

“This might indeed be a reflection that we are now undertaking more and more high-risk cases, particularly… with growing numbers of [older patients] and those with comorbidities,” Dr. Kunadian told TCTMD in an e-mail. 

Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), said in a telephone interview that the data are important because they provide a contemporary picture of mortality after PCI in the setting of cardiogenic shock in a large number of patients. He added that he was not surprised by the results.

“We have known that mortality is high immediately after the procedure, but that patients who survive do quite well,” Dr. Brener said, noting that the study shows a small reduction in mortality compared with that of 15 years ago among this patient population. He added that the factors associated with increased mortality are already relatively well established. 

Even so, the predictors provide some helpful insights, according to Dr. Kunadian.

“If an older diabetic patient with renal dysfunction presents with STEMI and shock, then we can predict from the outset that this patient is likely to be a patient who will not survive,” he said. “While perhaps a younger patient presenting with STEMI and shock without comorbidities has high likelihood of survival and should receive all possible support and care.”

Source:
Kunadian V, Qiu W, Ludman P, et al. Outcomes in patients with cardiogenic shock following percutaneous coronary intervention in the contemporary era: an analysis from the BCIS database (British Cardiovascular Intervention Society). J Am Coll Cardiol Intv. 2014;7:1374-1385.

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