Higher Mortality Observed in NSTEMI Than STEMI Shock Patients
New data from the ACC’s NCDR suggest substantial differences in the presentation, treatment and outcome between patients with STEMI and NSTEMI in cardiogenic shock. According a study published in Circulation: Cardiovascular Quality and Outcomes, NSTEMI patients with shock are older and sicker than their STEMI counterparts, less likely to undergo PCI and more likely to die.
The study looked at 235,541 patients with STEMI and NSTEMI treated at 392 U.S. hospitals between 2007 and 2011. The overall incidence of shock was 7.4 percent. Of the 93,229 (39.6 percent) patients with STEMI, 12.2 percent suffered shock. Among the 142,312 patients with NSTEMI, the incidence of shock was 4.3 percent. Patients with NSTEMI shock were significantly older than those with STEMI shock (71 versus 65 years, p<0.0001), were more often women (39.2 percent versus 36.6 percent, p=0.0007) and had higher rates of diabetes, previous heart failure, MI and revascularization, and peripheral artery disease.
Treatment differed between MI shock subtypes. Those with NSTEMI shock were less likely to receive acute medications such as aspirin, thienopyridine and glycoprotein IIb/IIIa inhibitors, and undergo PCI. Delays to PCI were also longer in patients with NSTEMI shock.
In-hospital mortality rates among patients with shock were high in both MI subtypes. Among STEMI patients, death rates in the shock and no-shock groups were 33.1 percent versus 2.0 percent, respectively. In the NSTEMI group, the death rates were 40.8 percent versus 2.3 percent, respectively. The difference in in-hospital mortality between STEMI shock and NSTEMI shock patients was statistically significant (p<0.0001).
The investigators noted the higher revascularization rates among STEMI shock patients and wrote, "Compared with STEMI, greater delays in time to revascularization and significantly greater adjusted mortality risk were observed in NSTEMI patients with shock. Given the continuously high mortality rates, we need new treatment strategies and support mechanisms specific to shock, as well as more attention and research geared toward exploring the acute and long-term impact of early cardiac catheterization and revascularization on outcomes [for] NSTEMI patients with shock."
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