Outcomes in Patients With Cardiogenic Shock Following Percutaneous Coronary Intervention in the Contemporary Era: An Analysis From the BCIS Database (British Cardiovascular Intervention Society) | Journal Scan

Study Questions:

What are contemporary rates of short- and long-term mortality among patients with cardiogenic shock (CGS) and acute coronary syndromes (ACS) who undergo percutaneous coronary intervention (PCI)? And, what clinical factors predict mortality?

Methods:

The study used prospectively collected data from the BCIS (British Cardiovascular Intervention Society) PCI database from 2005-2011. It included hospitals in England and Wales where tracking data were available to assess outcomes. Importantly, CGS was based on a clinical definition that this syndrome was present at the time of arrival to the cath lab. Missing data were also an issue and addressed using imputation approaches. The analysis relied on multivariable logistic regression.

Results:

In England and Wales, 6,489 patients underwent PCI for ACS in the setting of CGS. The mortality rates at 30 days, 90 days, and 1 year were 37.3%, 40.0%, and 44.3%, respectively. Using multivariable logistic regression, the authors noted not unsurprisingly that age, diabetes mellitus, renal disease, need for artificial mechanical ventilation, intra-aortic balloon pump use, and need for left main stem PCI were associated with higher mortality at 1 year.

Conclusions:

The authors concluded that among patients undergoing PCI in the context of CGS, mortality remains high despite use of contemporary PCI strategies. At least in these data from the United Kingdom, mortality seems to occur early, with long-term mortality more stable after the first 30 days.

Perspective:

This is an interesting study using the BCIS PCI database. CGS is a big clinical problem, as it is a substantial reason for early death in ACS. I do not believe the findings from this study would be too surprising to most practicing interventional cardiologists. The clinical factors they identified are fairly consistent with the prior literature (with perhaps the exception of diabetes). The bottom line message is also a key point to keep in mind: We have a ways to go as far as this critical group of patients is concerned. However, two caveats that readers need to keep in mind when interpreting these data (which the authors readily acknowledge in their paper): 1) several key variables, such as receiving resuscitation and cardiac arrest, are unavailable in this database, while others are missing at moderately high rates; and 2) it is critical to understand that this cohort only included patients who arrived to the hospital and were selected for PCI. This last issue is not a minor point, as it represents only those individuals who were selected to undergo these procedures. As other papers have demonstrated, this selection can be heavily influenced by several factors including public reporting of individual operator or hospital outcomes for PCI.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support , Interventions and ACS

Keywords: Acute Coronary Syndrome, Wales, Shock, Cardiogenic, England, Diabetes Mellitus, Intra-Aortic Balloon Pumping, Percutaneous Coronary Intervention, Respiration, Artificial


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