Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States

Abstract

Background: Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI).

Methods and results: We queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)<0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%, P(trend)<0.001) and intra-aortic balloon pump use (44.8% to 53.7%, P(trend)<0.001) in these patients over the 8-year period. Inhospital mortality decreased significantly, from 44.6% to 33.8% (P(trend)<0.001; adjusted OR, 0.71; 95% CI, 0.68 to 0.75), whereas the average total hospital cost increased from $35 892 to $45 625 (P(trend)<0.001) during the study period. There was no change in the average length of stay (P(trend)=0.394). These temporal trends were similar in patients <75 and ≥ 75 years of age, men and women, and across each racial/ethnic group.

Conclusions: The incidence of cardiogenic shock complicating STEMI has increased during the past 8 years together with increased use of early mechanical revascularization and intra-aortic balloon pumps. There has been a concomitant decrease in risk-adjusted inhospital mortality, but an increase in total hospital costs during this period.

Keywords: ST‐elevation myocardial infarction; cardiogenic shock; early revascularization; inhospital mortality; trends.

Figure 1.

Trends in incidence rates of cardiogenic shock in patients with STEMI. A, Cardiogenic shock (%) was calculated as the number of patients with cardiogenic shock divided by the number of patients with STEMI per year×100; P_trend<0.001. B, Trends in cardiogenic shock presented as unadjusted and adjusted odds ratios and 95% confidence intervals (CIs) for each year relative to 2003 (reference year). Regression model adjusted for demographics, hospital characteristics, 29 Elixhauser and other clinically relevant comorbidities, and presentation. OR indicates odds ratio; STEMI, ST‐elevation myocardial infarction.

Figure 2.

Age‐, sex‐, and race‐specific trends in incidence rates of cardiogenic in patients with ST‐elevation myocardial infarction (STEMI). A, Trends in incidence rates of cardiogenic shock in patients <75 and ≥75 years of age with STEMI; P_trend<0.001. B, Trends in incidence rates of cardiogenic shock in men and women with STEMI; P_trend<0.001. C, Trends in incidence rates of cardiogenic shock in whites, African Americans, Hispanics, and Asian/Pacific Islanders with STEMI; P_trend<0.001.

Figure 3.

Trends in early mechanical revascularization and IABP use in patients with cardiogenic shock complicating STEMI. A, Early mechanical revascularization was defined as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) within 24 hours of admission; P_trend<0.001. B, Trends in early mechanical revascularization presented as unadjusted and adjusted odds ratios and 95% confidence intervals (CIs) for each year relative to 2003 (reference year). Regression model adjusted for demographics, hospital characteristics, 29 Elixhauser and other clinically relevant comorbidities, and presentation. C, IABP (%) was calculated as the number of patients undergoing IABP placement divided by the number of patients with STEMI complicated by cardiogenic shock per year×100; P_trend<0.001. D, Trends in IABP use presented as unadjusted and adjusted odds ratios and 95% CIs for each year relative to 2003 (reference year). Regression model adjusted for demographics, hospital characteristics, 29 Elixhauser and other clinically relevant comorbidities, and presentation. IABP indicates intra‐aortic balloon pump; OR, odds ratio; STEMI, ST‐elevation myocardial infarction.

Figure 4.

Age‐, sex‐, and race‐specific trends in early mechanical revascularization and IABP use in patients with cardiogenic shock complicating STEMI. Trends in early mechanical revascularization in (A) patients <75 and ≥75 years of age, (B) men and women, and (C) whites, African Americans, Hispanics, and Asian/Pacific Islanders, and IABP use in (D) patients <75 and ≥75 years of age, (E) men and women, and (F) whites, African Americans, Hispanics, and Asian/Pacific Islanders, with cardiogenic shock complicating STEMI; P_trend<0.001 for all. IABP indicates intra‐aortic balloon pump; STEMI, ST‐elevation myocardial infarction.

Figure 5.

Trends in inhospital mortality in patients with cardiogenic shock complicating STEMI. A, Inhospital mortality (%) was calculated as the number of patients who died during hospitalization divided by the number of patients with STEMI complicated by cardiogenic shock per year×100; P_trend<0.001. B, Trends in inhospital mortality presented as unadjusted and adjusted odds ratios and 95% confidence intervals (CIs) for each year relative to 2003 (reference year). Regression model adjusted for demographics, hospital characteristics, 29 Elixhauser and other clinically relevant comorbidities, and presentation. OR indicates odds ratio; STEMI, ST‐elevation myocardial infarction.

Figure 6.

Age‐, sex‐, and race‐specific trends in inhospital mortality in patients with cardiogenic shock complicating ST‐elevation myocardial infarction (STEMI). Trends in inhospital mortality in (A) patients <75 and ≥75 years of age, (B) men and women, and (C) whites, African Americans, Hispanics, and Asian/Pacific Islanders with cardiogenic shock complicating STEMI; P_trend<0.001 for all.

Figure 7.

Overall and age‐, sex‐, and race‐specific trends in average length of stay in patients with cardiogenic shock complicating ST‐elevation myocardial infarction (STEMI). Trends in average length of stay (days) in patients with cardiogenic shock complicating STEMI (A) overall, (B) in patients <75 and ≥75 years of age, (C) in men and women, and (D) in whites, African Americans, Hispanics, and Asian/Pacific Islanders; P_trend>0.001 for all.

Figure 8.

Overall and age‐, sex‐, and race‐specific trends in average total hospital cost in patients with cardiogenic shock complicating ST‐elevation myocardial infarction (STEMI). Trends in average total hospital cost ($) in patients with cardiogenic shock complicating STEMI (A) overall, (B) in patients <75 and ≥75 years of age, (C) in men and women, and (D) in whites, African Americans, Hispanics, and Asian/Pacific Islanders; P_trend<0.001 for all.