Hemodynamic profiles of STEMI patients at admission - prevalence and short-term outcomes of the novel PRESHOCK phenotype

Background

Cardiogenic shock (CS) remains a severe complication of acute myocardial infarction with high morbidity and mortality. Data from acute heart failure cohorts suggest that transitional haemodynamic instability (“PRESHOCK”) is associated with adverse outcomes. Whether this concept applies to ST-segment elevation myocardial infarction (STEMI), a leading cause of CS, has not been systematically studied. Early identification may offer a window for timely haemodynamic support.

Purpose

To assess the prevalence and short-term outcomes of the PRESHOCK phenotype at admission in STEMI patients compared with no-shock and shock phenotypes, and to evaluate its predictive value for clinical deterioration.

Methods

This multicentre metropolitan STEMI registry included patients enrolled between January 2024 and October 2025. Classification was based on a single haemodynamic assessment at admission to evaluate early instability as a predictor of subsequent shock (see A). Categorical variables were analysed using χ² or Fisher’s exact tests, and continuous variables using Mann–Whitney U or Kruskal–Wallis tests. Outcomes included overt CS (developed after coronary angiography, adjudicated by the treating physician), mechanical circulatory support (MCS), and in-hospital mortality.

Results

Among 1,128 STEMI patients, 300 had complete haemodynamic data and were analysed: 109 no-shock, 125 PRESHOCK, and 66 shock (see B). In the PRESHOCK group, 108 had isolated hypoperfusion and 17 isolated hypotension. Estimated PRESHOCK prevalence was ≥11.1% in the overall registry and 41.7% in the analysed cohort.

Baseline characteristics were comparable across groups. Overt CS occurred in 9.8% of STEMI cases. Based on admission status, rates were 0.9% in the no-shock group, 8.8% in the PRESHOCK group, and 26.6% in the shock group (see C, p<0.001). Patients in the PRESHOCK group had a significantly higher risk of progressing to overt CS than those in the no-shock group (p<0.01). After exclusion of resuscitated cases, this finding remained broadly consistent (0.9% vs. 5.7%, p=0.053). MCS was utilised in 32 cases overall, with differences mainly driven by the shock group (31.8%), while rates were comparable between no-shock (2.8%) and PRESHOCK (6.5%) patients (p=0.18). In-hospital mortality was highest in the shock group (45.5%), with no significant difference observed between the no-shock (3.7%) and PRESHOCK groups (4.8%, p=0.66).

Conclusion

At least one in nine patients with STEMI met the criteria for PRESHOCK at admission. The novel STEMI-PRESHOCK status identified a subgroup at increased risk of developing overt CS. Recognition of this phenotype on admission may facilitate proactive risk stratification and the timely initiation of haemodynamic support. Future research should further characterise the STEMI-PRESHOCK population, and evaluate targeted therapeutic approaches aimed at preventing progression to CS.Figure