Circulatory Support Escalation in Acute Myocardial Infarction-Related vs Heart Failure Cardiogenic Shock: Insights from an International, Multicenter Cardiac Intensive Care Registry

Purpose: To assess frequency, outcomes, and differential patterns of circulatory support escalation in acute myocardial infarction-related (AMI) and heart failure (HF) cardiogenic shock (CS). Methods: This is a retrospective observational study including consecutive patients with CS (SCAI class B to E) from 4 cardiac intensive care units. Escalation was defined as any incremental change in the circulatory support strategy after an initial bundle of care was established for at least 4 hours. Results: Among 501 consecutive CS patients, escalation occurred in 29.9%, with no significant difference between AMI-CS and HF-CS (26.1 vs 32.7%, p=0.114). Hospital mortality did not differ between between the groups (27.5 vs 29.6%; p=0.617), nor among escalated patients, (44.4% vs 45.8%; p 0.870), HF-CS patients presented a trend towards greater transition to heart replacement therapies (31.2 vs 18.5%, p=0.091). On admission, AMI-CS patients were more likely on temporary mechanical circulatory support (tMCS; 35.0 vs 13.5%, p=0.002) with a prevalence of Impella devices (50.0 vs 13.3%, p<0.001); HF-CS patients presented worse right ventricular function as expressed by lower TAPSE values (15.0 vs 18.0 mm, p<0.001). We found no significant difference in time to escalation nor in SCAI class between the two groups; HF-CS were more often started on inotropes or vasopressors (39.5 vs 24.1%, p=0.054), while AMI-CS patients were more frequently escalated to tMCS and submitted to multiple escalations (30.2% vs 14.7%, p=0.025). In AMI-CS, escalation was associated with a higher risk of complications (50.0 vs 30.0%, p=0.016) mainly driven by hemocompatibility-related adverse events (40.7 vs 22.0%, p=0.062). Conclusion: In a multicenter international cohort of CS patients, AMI-CS and HF-CS patients presented high rates and different patterns of circulatory support escalation, with no significant difference in hospital mortality.