1

Introduction

Cardiogenic shock (CS) is the most common cause of in-hospital mortality in patients with acute ST-elevation myocardial infarction (STEMI) [ , ]. More than 90,000 patients with STEMI and CS present in the United States every year with in-hospital mortality rate of almost 50% [ , ]. The adoption of early revascularization to restore blood flow in the culprit artery with newer generation of stents and the use of adjunctive pharmacotherapy and support devices have shown promising results with improved overall outcomes. However, patients with CS in the acute phase of a STEMI still have major short- and long-term morbidity and mortality. Previous studies have shown that in STEMI patients undergoing primary percutaneous coronary intervention (PCI), a history of prior coronary artery bypass graft surgery (CABG) was associated with a delay in coronary reperfusion, adjusted and unadjusted higher in hospital mortality rates and prolonged length of stay when compared with patients that had a history of prior PCI [ ]. Furthermore, patients with a history of CABG are at an increased risk of ischemic stroke on long-term follow up and intervention on a saphenous vein graft compared with intervention of a native vessel has been shown to be associated with a remarkably worse procedural and clinical outcome [ ]. Conversely, patients with a prior history of percutaneous revascularization have similar outcomes to revascularization naïve patients [ ]. However data on the impact of prior revascularization by either CABG or PCI in CS patients undergoing primary PCI in the setting of a STEMI is scarce. Although there have been ongoing efforts to improve the outcome of CS patients with early reperfusion strategies and the use of novel mechanical circulatory support devices, the prognosis and optimal strategies in this patient population remain largely unknown. The purpose of this study was to assess whether prior revascularization, and more specifically, the type of revascularization, CABG or PCI, had an effect on the overall prognosis of STEMI patients presenting with CS and undergoing primary PCI.

2

Methods

Between 1/2010 and 5/2017, a total of 241 patients were admitted to our institution with an STEMI and CS. As per the New York State Department of Health Percutaneous Coronary Intervention Report (PCIRS), CS was defined as acute hypotension (systolic blood pressure < 80 mm Hg) or low cardiac index (<2.0 L/min/m ² ) despite pharmacological or mechanical support ( https://www.health.ny.gov/forms/cardiac_surgery/2011/pcirs/pcirs_instructions.pdf ). All patients included in the study underwent primary PCI. Baseline clinical, angiographic and procedural characteristics, as well as in-hospital outcomes were prospectively collected among all patients as part of the New York State PCIRS data system collection. The primary endpoint of the present study was in-hospital major adverse cardiac and cerebrovascular events (MACCE) defined as all-cause mortality, stroke or transient ischemic attack, reinfarction, major bleeding or any repeat revascularization. Secondary endpoints included the individual endpoints and MACCE at 12 months follow-up. PCIRS was created in 1992 for the purpose of evaluating and improving the quality of PCI in New York through the risk adjustment of outcomes and dissemination of reports to hospitals, cardiologists, and the public and therefore waiver of consent was granted under the common rule by the local institutional Review Board.

Data are expressed as mean ± SD or median as appropriate. Chi-square tests with exact p -values based on Monte Carlo simulation were utilized to examine the marginal association between categorical variables (gender, white race or not, current smoker, former smoker, hypertension, dyslipidemia, diabetes mellitus, peripheral vascular disease, chronic lung disease, congestive heart failure, prior myocardial infarction, prior cerebrovascular event, chronic dialysis, 7 specific culprit vessels, thrombus present, previously stented lesion, multivessel PCI, multivessel disease, drug eluting stent, bifurcation lesion, lesion complexity, ejection fraction ≥ 50%, ejection fraction ≤ 30%, LVEDP/PCWP>20, multiple pressors, intra-aortic balloon counter pulsation, left ventricular assist device, ECMO, cardiac arrest (any patient that required out of hospital, in transit or at the hospital cardioversion and/or CPR), in-hospital and 30 day mortality, 90 day mortality, 12 month mortality, reinfarction, major bleeding complication, stroke, MACCE, urgent revascularization, TIMI minor bleeding, angiographic success, 30-day readmission rate) and patient group (prior CABG vs prior PCI vs no prior revascularization, in addition to prior revascularization vs no prior revascularization), as well as between patients’ group, comorbidities and 12-month mortality. Welch’s tests with unequal variance were used to examine marginal association between continuous variables (age, hemoglobin, CPK, peak troponin I, peak troponin T, creatinine, lactate) and patient group (prior CABG vs prior PCI vs no prior revascularization or prior revascularization vs no prior revascularization), as well as between patients’ age and 12-month mortality. Factors that were significantly associated with 12-month mortality ( p < 0.05) were further considered as possible risk factors for 12-month mortality in a multivariable logistic regression model. An odds ratio (OR) > 1 suggested a higher 12-month mortality risk while an OR < 1 suggested a lower 12-month mortality risk. Statistical analysis was performed using SAS 9.4 and significance level was set at 0.05 (SAS Institute Inc., Cary, NC).

2

Methods

Between 1/2010 and 5/2017, a total of 241 patients were admitted to our institution with an STEMI and CS. As per the New York State Department of Health Percutaneous Coronary Intervention Report (PCIRS), CS was defined as acute hypotension (systolic blood pressure < 80 mm Hg) or low cardiac index (<2.0 L/min/m ² ) despite pharmacological or mechanical support ( https://www.health.ny.gov/forms/cardiac_surgery/2011/pcirs/pcirs_instructions.pdf ). All patients included in the study underwent primary PCI. Baseline clinical, angiographic and procedural characteristics, as well as in-hospital outcomes were prospectively collected among all patients as part of the New York State PCIRS data system collection. The primary endpoint of the present study was in-hospital major adverse cardiac and cerebrovascular events (MACCE) defined as all-cause mortality, stroke or transient ischemic attack, reinfarction, major bleeding or any repeat revascularization. Secondary endpoints included the individual endpoints and MACCE at 12 months follow-up. PCIRS was created in 1992 for the purpose of evaluating and improving the quality of PCI in New York through the risk adjustment of outcomes and dissemination of reports to hospitals, cardiologists, and the public and therefore waiver of consent was granted under the common rule by the local institutional Review Board.

Data are expressed as mean ± SD or median as appropriate. Chi-square tests with exact p -values based on Monte Carlo simulation were utilized to examine the marginal association between categorical variables (gender, white race or not, current smoker, former smoker, hypertension, dyslipidemia, diabetes mellitus, peripheral vascular disease, chronic lung disease, congestive heart failure, prior myocardial infarction, prior cerebrovascular event, chronic dialysis, 7 specific culprit vessels, thrombus present, previously stented lesion, multivessel PCI, multivessel disease, drug eluting stent, bifurcation lesion, lesion complexity, ejection fraction ≥ 50%, ejection fraction ≤ 30%, LVEDP/PCWP>20, multiple pressors, intra-aortic balloon counter pulsation, left ventricular assist device, ECMO, cardiac arrest (any patient that required out of hospital, in transit or at the hospital cardioversion and/or CPR), in-hospital and 30 day mortality, 90 day mortality, 12 month mortality, reinfarction, major bleeding complication, stroke, MACCE, urgent revascularization, TIMI minor bleeding, angiographic success, 30-day readmission rate) and patient group (prior CABG vs prior PCI vs no prior revascularization, in addition to prior revascularization vs no prior revascularization), as well as between patients’ group, comorbidities and 12-month mortality. Welch’s tests with unequal variance were used to examine marginal association between continuous variables (age, hemoglobin, CPK, peak troponin I, peak troponin T, creatinine, lactate) and patient group (prior CABG vs prior PCI vs no prior revascularization or prior revascularization vs no prior revascularization), as well as between patients’ age and 12-month mortality. Factors that were significantly associated with 12-month mortality ( p < 0.05) were further considered as possible risk factors for 12-month mortality in a multivariable logistic regression model. An odds ratio (OR) > 1 suggested a higher 12-month mortality risk while an OR < 1 suggested a lower 12-month mortality risk. Statistical analysis was performed using SAS 9.4 and significance level was set at 0.05 (SAS Institute Inc., Cary, NC).

3

Results

A total of 241 consecutive patients with STEMI and CS underwent primary PCI at our institution between 1/2010 and 5/2017. Among these patients, 12 had a history of prior CABG and 53 prior PCI, whereas 176 patients were revascularization-naïve. The patient population studied was predominantly white males, with an average age of 65 with the CABG patient population being on average approximately 9 years older ( Table 1 ). Post CABG patients were more likely to have more comorbidities, such as diabetes, hypertension and dyslipidemia. Conversely, patients with no prior revascularization were more likely to be active smokers, with lower incidence of prior heart failure, peripheral vascular disease, severely reduced left ventricular ejection fraction or prior myocardial infarction. Angiographic characteristics are shown in Table 2 and while CABG patients had more graft disease, there was no statistical significance in the distribution of other culprit vessels between the three groups ( Table 2 ). There was no statistical significance between the groups with respect to frequency of cardiac arrest on presentation or with respect to the degree of pharmacologic support despite the obvious difference in infarct size as measured by laboratory values such as troponins, CPK, and lactate all of which were demonstrably larger in patients with no prior revascularization. Multivessel PCI was attempted in only 18% of patients and drug eluting stents were deployed in 62.1% of patients. Only 42.9% of patients that had a history of prior PCI were treated with a drug eluting stents, compared to 50% in patients that had a prior CABG and 68% of patients that were revascularization naïve ( p = 0.007). More than 70% of the patients had some type of temporary percutaneous mechanical circulatory support device implanted, with the predominant device being an intra-aortic balloon pump and/or Impella® (Abiomed Inc., Danvers, MA, USA) that was implanted in 50% of patients with history of prior CABG, 70% of patients with history of prior PCI and 64% of patients that were revascularization-naïve ( p = 0.39). A veno-arterial extracorporeal membrane oxygenator (ECMO) was used only in 9.7% of patients with no prior history of surgical or percutaneous revascularization.

Table 2

Angiographic, procedural characteristics and laboratory values.

	Prior CABG (N = 12)	Prior PCI (N = 53)	No prior revascularization (N = 176)	P
Left main (%)	1 (8.3%)	3 (5.8%)	12 (6.9%)	0.56
Left anterior descending (%)	4 (33.3%)	25 (48.1%)	85 (49.1%)	0.59
Left circumflex (%)	1 (8.3%)	6 (11.5%)	22 (12.7%)	0.53
Right coronary (%)	2 (16.7%)	23 (44.2%)	75 (43.4%)	0.21
Branch vessel (%)	1 (8.3%)	11 (21.2%)	17 (9.8%)	0.09
Ramus (%)	0 (0.0%)	2 (3.9%)	2 (1.2%)	0.37
Grafts (arterial or venous) (%)	8 (66.7%)	NA	NA	NA
Thrombus present (%)	7 (63.6%)	34 (65.4%)	127 (73.8%)	0.46
Previously stented lesion (%)	3 (27.7%)	32 (64.0%)	0 (0%)	<0.0001
Multivessel intervention (%)	3 (25.0%)	11 (21.2%)	29 (16.8%)	0.64
Multivessel disease (%)	12 (100.0%)	36 (69.2%)	117 (67.2%)	0.06
Drug eluting stent (%)	4 (50.0%)	18 (42.9%)	106 (68.0%)	0.007
Bifurcation lesion (%)	3 (33.3%)	8 (29.6%)	53 (44.5%)	0.36
Lesion complexity: High/C (%)	8 (72.7%)	26 (78.8%)	100 (84.8%)	0.51
Ejection fraction ≥50% (%)	4 (33.3%)	9 (17.7%)	44 (27.5%)	0.29
Ejection fraction ≤30% (%)	6 (50.0%)	27 (54.0%)	58 (36.3%)	0.07
LVEDP/PCWP>20 (%)	6 (50.0%)	27 (54.0%)	92 (52.2%)	0.45
Intra-aortic balloon pump (%)	6 (50%)	27 (54.0%)	58 (36.3%)	0.07
Impella (%)	0 (0%)	10 (18.9%)	54 (30.7%)	<0.0001
ECMO (%)	0 (0%)	0 (0%)	17 (10%)	0.38
Hemoglobin (g/dL)	11.2 ± 3.5	12.5 ± 2.2	13.3 ± 2.2	0.02
CPK (IU/L)	133.0 ± 18.4	2809.3 ± 3645.6	4601.6 ± 5564.1	<0.0001
Peak Troponin I (ng/mL)	127.7 ± 164.0	360.7 ± 538.3	282.8 ± 503.8	0.03
Peak Troponin T (ng/mL)	4.06 ± 2.8	4.99 ± 3.3	20.25 ± 24.4	0.04
Creatinine (mg/dL)	1.60 ± 2.17	1.13 ± 0.66	1.18 ± 0.75	0.71
Lactate (mmol/L)	1.38 ± 0.54	4.99 ± 4.52	6.06 ± 5.00	<0.0001

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