title: Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock.
abstract: The role and timing of percutaneous mechanical circulatory support (MCS) devices in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS) are not well understood. We sought to evaluate patient characteristics and predictors of outcomes in patients presenting with AMICS supported with an axial flow percutaneous MCS device; 287 consecutive unselected patients enrolled in the catheter-based ventricular assist device registry presenting with AMICS who underwent percutaneous coronary intervention (PCI) were included in this analysis. All patients were supported with either the Impella 2.5 or Impella CP. Mean patient age was 66 ± 12.5 years, 76% were men, and mean left ventricular ejection fraction was 25 ± 12%. Before receiving MCS, 80% of patients required inotropes or vasopressors and 40% were supported with intra-aortic balloon pump; 9% of patients were under active cardiopulmonary resuscitation at the time of MCS implantation. Survival to discharge was 44%. In a multivariate analysis, early implantation of a MCS device before PCI (p = 0.04) and before requiring inotropes and vasopressors (p = 0.05) was associated with increased survival. Survival was 66% when MCS was initiated <1.25 hours from shock onset, 37% when initiated within 1.25 to 4.25 hours, and 26% when initiated after 4.25 hours (p = 0.017). Survival was 68%, 46%, 35%, 35%, and 26% for patients requiring 0, 1, 2, 3, and ≥4 inotropes before MCS support, respectively (p <0.001). In conclusion, MCS implantation early after shock onset, before initiation of inotropes or vasopressors and before PCI, is independently associated with improved survival in patients presenting with AMICS.
authors.affiliation: Division of Cardiology, Henry Ford Hospital/Wayne State University, Detroit, Michigan.
authors.forename: Mir B
authors.initials: MB
authors.lastname: Basir
authors.affiliation: Division of Cardiology, Detroit Medical Center/Wayne State University, Detroit, Michigan.
authors.forename: Theodore L
authors.initials: TL
authors.lastname: Schreiber
authors.affiliation: Division of Cardiology, Detroit Medical Center/Wayne State University, Detroit, Michigan.
authors.forename: Cindy L
authors.initials: CL
authors.lastname: Grines
authors.affiliation: Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan.
authors.forename: Simon R
authors.initials: SR
authors.lastname: Dixon
authors.affiliation: Columbia University Medical Center/New York-Presbyterian Hospital, Cardiovascular Research Foundation, New York, New York.
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Moses
authors.affiliation: Division of Cardiology, Tenet Healthcare, Delray, Florida.
authors.forename: Brijeshwar S
authors.initials: BS
authors.lastname: Maini
authors.affiliation: Division of Cardiology, Henry Ford Hospital/Wayne State University, Detroit, Michigan.
authors.forename: Akshay K
authors.initials: AK
authors.lastname: Khandelwal
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.affiliation: Division of Cardiology, Henry Ford Hospital/Wayne State University, Detroit, Michigan. Electronic address: woneill1@hfhs.org.
authors.forename: William W
authors.initials: WW
authors.lastname: O'Neill
mesh_terms: D000368:Aged; D005260:Female; D006353:Heart-Assist Devices; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D012042:Registries; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000401:mortality / Q000628:therapy*; D015996:Survival Rate; D016896:Treatment Outcome