Early versus delayed coronary angiography in cardiogenic shock: a mimic-iv cohort study
P Darko, B Otchere, E Hama, P Berchie, E Vince, X Salazar, B Demoss, A Krishnamoorthy, R Singh, R Loungani, K Bauza, S Damle, E Molina, C MartiAbstract
Background
Early coronary angiography is frequently advocated in the management of cardiogenic shock, particularly when an ischaemic aetiology is suspected. Guideline recommendations emphasise rapid invasive evaluation, yet real-world evidence supporting the optimal timing of left heart catheterisation (LHC) in unselected shock populations remains limited. In routine practice, delays in angiography may occur because of haemodynamic instability, competing clinical priorities, or resource constraints. Understanding the relationship between LHC timing and outcomes in cardiogenic shock is therefore essential for informing systems of care and interpreting observational data.
Purpose
To evaluate the association between timing of left heart catheterisation and in-hospital outcomes among critically ill patients with cardiogenic shock.
Methods
We conducted a retrospective cohort study using the medical information mart for intensive care IV (mimic-iv) database. Adult ICU patients with cardiogenic shock were identified using diagnostic codes. Patients were stratified according to timing of LHC relative to ICU admission: within 24 hours, more than 24 hours after admission, or no LHC during hospitalisation. The primary outcome was in-hospital mortality. Secondary outcomes included ICU length of stay. Multivariable logistic regression was performed among patients who underwent LHC, adjusting for age and sex, to compare mortality between early and delayed catheterisation.
Results
Among 1,290 patients with cardiogenic shock, 360 underwent LHC within 24 hours of ICU admission, 92 underwent LHC after 24 hours, and 838 did not undergo LHC. In-hospital mortality differed substantially across groups: 28.6% (n=103) in the within-24-hour LHC group, 21.7% (n=20) in the >24-hour LHC group, and 45.1% (n=378) among patients who did not undergo LHC. Among patients who received catheterisation, LHC performed more than 24 hours after ICU admission was not associated with higher in-hospital mortality compared with LHC within 24 hours (adjusted odds ratio 0.78, 95% confidence interval 0.46–1.34). ICU length of stay was similar across LHC timing groups.
Conclusion
Among patients with cardiogenic shock who underwent left heart catheterisation, delayed LHC beyond 24 hours was not associated with higher adjusted in-hospital mortality compared with catheterisation within 24 hours. This finding contrasts with established evidence supporting time-dependent benefits of early revascularisation and likely reflects survivor bias inherent to retrospective analyses, whereby patients stable enough to undergo delayed catheterisation represent a lower-risk subset. The markedly higher mortality observed among patients who did not undergo LHC reinforces the central role of early invasive evaluation in the management of cardiogenic shock and highlights the need for cautious interpretation of timing analyses in observational datasets.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.