Udhay Krishnan1, Josef A Brejt2, Joshua Schulman-Marcus3, Rajesh V Swaminathan4, Dmitriy N Feldman2, S Chiu Wong2, Parag Goyal2, Evelyn M Horn2, Maria Karas2, Irina Sobol2, Robert M Minutello2, Geoffrey Bergman2, Harsimran Singh2, Luke K Kim2. 1. Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, United States. Electronic address: udk9001@nyp.org. 2. Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, United States. 3. Albany Medical Center Division of Cardiology, 47 New Scotland Rd, MC-44, Albany, NY 12208, United States; Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, United States. 4. Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, United States.
Abstract
BACKGROUND: Multiple studies have reported a decline in mortality for patients with cardiogenic shock after acute myocardial infarction (CS-AMI), a finding which has been attributed to an increase in revascularization over the past decade. However, other studies that have focused on CS-AMI patients treated with early percutaneous coronary intervention (PCI) have found no improvement in risk-adjusted mortality. To reconcile these discordances, we hypothesize that the clinical complexity of the PCI-population has changed over time, in ways not precisely adjusted for in previous studies. METHODS: We conducted a retrospective analysis of the 2005-2012 Nationwide Inpatient Sample. Patients with CS-AMI who underwent PCI within 24h of hospitalization were identified. Temporal trends in clinical characteristics and in-hospital mortality were analyzed. RESULTS: There was no significant change in un-adjusted in-hospital mortality (30% in 2005-2006 and 27.8% in 2011-2012, OR: 0.90; 95% CI: 0.79-1.01, p=0.07). There was an increase in the proportion of patients with ≥3 Elixhauser comorbidities and comorbidity scores ≥5. The population of patients that suffered from cardiac arrest or needed intubation on the first hospital day increased from 27.8% to 42.6% (ptrend<0.001). In a multivariate analysis, mortality rates in 2011-2012 versus 2005-2006 decreased significantly (OR: 0.75; 95% CI: 0.65-0.85, p<0.001). CONCLUSIONS: During a period that corresponds to expanded PCI use and improved prehospital survival, risk-adjusted mortality declined. Much of the survival benefit attributable to early revascularization has been neutralized by an increase in prevalence of "extreme-risk" patients. This may contribute to the null effect on in-hospital mortality.
BACKGROUND: Multiple studies have reported a decline in mortality for patients with cardiogenic shock after acute myocardial infarction (CS-AMI), a finding which has been attributed to an increase in revascularization over the past decade. However, other studies that have focused on CS-AMIpatients treated with early percutaneous coronary intervention (PCI) have found no improvement in risk-adjusted mortality. To reconcile these discordances, we hypothesize that the clinical complexity of the PCI-population has changed over time, in ways not precisely adjusted for in previous studies. METHODS: We conducted a retrospective analysis of the 2005-2012 Nationwide Inpatient Sample. Patients with CS-AMI who underwent PCI within 24h of hospitalization were identified. Temporal trends in clinical characteristics and in-hospital mortality were analyzed. RESULTS: There was no significant change in un-adjusted in-hospital mortality (30% in 2005-2006 and 27.8% in 2011-2012, OR: 0.90; 95% CI: 0.79-1.01, p=0.07). There was an increase in the proportion of patients with ≥3 Elixhauser comorbidities and comorbidity scores ≥5. The population of patients that suffered from cardiac arrest or needed intubation on the first hospital day increased from 27.8% to 42.6% (ptrend<0.001). In a multivariate analysis, mortality rates in 2011-2012 versus 2005-2006 decreased significantly (OR: 0.75; 95% CI: 0.65-0.85, p<0.001). CONCLUSIONS: During a period that corresponds to expanded PCI use and improved prehospital survival, risk-adjusted mortality declined. Much of the survival benefit attributable to early revascularization has been neutralized by an increase in prevalence of "extreme-risk" patients. This may contribute to the null effect on in-hospital mortality.