Differences in short- and long-term prognostic determinants according to etiology in cardiogenic shock
S Kawanami, Y Egami, K Nagai, R Muroya, H Mastubara, T Mukai, N Kobayashi, A Sugino, M Abe, H Nohara, N Okamoto, Y Matsunaga, M Yano, M NishinoAbstract
Background
Cardiogenic shock (CS) is a life-threatening condition most commonly caused by acute myocardial infarction (AMI). While timely revascularization has improved outcomes in AMI-related CS, effective therapies for non-AMI CS remain limited, highlighting etiological differences. However, data on long-term outcomes and their prognostic determinants are scarce.
Purpose
This study aimed to evaluate differences in short- and long-term prognostic determinants according to etiology in patients with cardiogenic shock.
Methods
Consecutive patients admitted to our institute with AMI or acute decompensated heart failure between January 2015 and December 2024 were retrospectively identified. Patients requiring vasopressors and/or mechanical circulatory support during hospitalization were defined as having CS and included. To account for time-dependent effects, landmark analyses at 30 days were performed, separating early (0–30 days) and late (30–365 days) phases, and multivariable Cox proportional hazards models were constructed for each phase.
Results
Among the 567 patients included, 243 had AMI-related CS and 324 had non-AMI-related CS. In the AMI-related CS group, the median age was 74 years (IQR, 64–81). SCAI stages C, D, and E were observed in 23.1%, 51.9%, and 25.1% of patients, respectively. IABP, Impella, and ECMO were used in 49.0%, 25.9%, and 25.1% of patients. PCI was performed in 97.5% of patients, and CABG in 2.1%. Among patients with non-AMI CS, the median age was 78 years (IQR, 71–85). The underlying etiologies included ischemic heart disease (34.3%), cardiomyopathy (32.1%), valvular heart disease (18.2%), and myocarditis (1.5%). Early outcomes did not differ between AMI-related and non-AMI-related CS (log-rank P = 0.38). However, during the late phase, AMI-related CS was associated with significantly better event-free survival (log-rank P < 0.01) (Figure 1). Early outcomes were driven by shock severity, whereas late outcomes were primarily determined by etiology, with AMI-related CS associated with better prognosis (HR 0.27 95%CI 0.12-0.61, P value<0.01). (Figure 2) Early outcomes were driven by shock severity, including hypotension, renal dysfunction, and SCAI stage E, regardless of etiology. In AMI-related CS, frailty emerged as the main determinant of late outcomes, whereas in non-AMI-related CS, prior heart failure and lower systolic blood pressure at shock onset remained independently associated with adverse late outcomes.
Conclusions
Prognostic determinants in cardiogenic shock varied by etiology and time phase, with early outcomes driven by shock severity and late outcomes by etiology-specific factors. These findings highlight the importance of phase- and etiology-specific risk stratification in patients with cardiogenic shock.Figure 1Figure 2