Early versus differed invasive strategy in STEMI complicated by cardiogenic shock

Abstract

Cardiogenic shock (CC) is a devastating complication of the ST elevation acute myocardial infarction (STEMI). Its mortality remains high despite the huge progress in critical care and coronary revascularization. We aim in this study to compare PCI results and impact on in-hospital mortality of early invasive strategy (EIS) compared to differed invasive strategy (DIS) in CC complicating a STEMI (CC-STEMI). It is a retrospective, mono-centric study including 267 patients from the MIRAMI registry who presented a CC-STEMI between 1995 and 2016. EIS was performed in 114 patients (99 primary PCI: 37%; 15 rescue PCI: 5.6%). DIS was performed after medical stabilization in 64 patients (23.9%) among those who didn’t undergo an early coronarography at a mean delay of 9.3 ± 8.8 days. All patients in the EIS group had a PCI using only balloon or stent, in the other hand only 39 (61%) patients in the DIS group had a PCI. One patient only was sent for CABG. Procedural success was significantly higher in the DIS (87.2%) compared to the EIS group (63.2%) ( P = 0.005). This difference was explained by the fact that in the EIS group there was more renal failure ( P = 0.003) more TIMI 0 flow ( P < 0.001), more thrombus ( P < 0.001) and less previous thrombolysis ( P < 0.001). Global in-hospital mortality rate was 49.1%. It was significantly higher in the EIS group compared to the DIS group (53.5% vs. 12.5%; P < 0.001). This was also explained by the higher rate of renal impairment ( P = 0.003), of anemia ( P = 0.013), of ventricular fibrillation ( P = 0.007), of PCI failure (p = 0.005) and of use of mechanical ventilation ( P = 0.002) in the EIS group. EIS didn’t show a significant reduction of the in-hospital mortality even in the SHOCK trial. The choice between the EIS and the DIS in our context was guided by the logistical issues and the patient's clinical condition.