Patterns and predictors of discharge guideline-directed medical therapy in survivors of acute myocardial infarction–related cardiogenic shock

Background

Guideline-directed medical therapy (GDMT) after cardiogenic shock is increasingly recognized as a determinant of long-term outcomes, yet most data describe heterogeneous shock etiologies. In acute myocardial infarction–related cardiogenic shock (AMI-CS), the clinical factors that influence discharge GDMT prescription remain unclear, especially across left ventricular ejection fraction (LVEF) phenotypes.

Purpose

We aimed to describe discharge GDMT patterns in AMI-CS survivors grouped by discharge LVEF and to model AMI-CS-specific clinical predictors of GDMT prescription.

Methods

We performed a retrospective analysis of adult AMI-CS survivors and stratified patients by discharge LVEF (≤40% vs >40%). Discharge GDMT was categorized by class (beta-blocker; renin–angiotensin–aldosterone system inhibitors [RAASi: ACEi/ARB/ARNI/MRA]; SGLT2 inhibitor). We used a multivariable logistic regression model to identify independent predictors of discharge RAASi and beta-blocker prescription.

Results

Among 892 AMI-CS survivors, 829 with discharge echocardiography data were analyzed (LVEF >40%: n=297; LVEF ≤40%: n=532). Patients with LVEF >40% were more often female (32.0% vs 24.8%, p=0.026) and were revascularized more often (86.2% vs 77.6%, p=0.003). Patients with LVEF ≤40% more often required mechanical circulatory support (74.1% vs 67.3%, p=0.040), with no difference in device type. Discharge creatinine was higher in LVEF ≤40% (median 1.1 [0.9–1.5] vs 1.0 [0.8–1.3], p<0.001), while discharge hemodialysis rates were similar (5.7% vs 7.1%, p=0.43).

At discharge, RAASi use was lower in LVEF >40% vs ≤40% (44.8% vs 53.9%, p=0.011), beta-blocker use was similar (p=0.30), and SGLT2 inhibitor use was low overall but prescribed more in LVEF ≤40% (4.3% vs 1.0%, p=0.009).

Multivariable analysis showed that older age (aOR 0.98, 95% CI 0.97–0.99; p<0.001) and severe renal dysfunction (creatinine >2.5 mg/dL and/or discharge hemodialysis: aOR 0.27, 95% CI 0.17–0.43; p<0.001) reduced odds of RAASi prescription, while LVEF ≤40% predicted higher odds (aOR 1.61, 95% CI 1.22–2.15; p<0.001). Similarly, older age (aOR 0.97, 95% CI 0.96–0.99; p=0.001) and renal dysfunction (aOR 0.55, 95% CI 0.33–0.94; p=0.023) were associated with lower odds of beta-blocker prescription.

Conclusion

In AMI-CS survivors, discharge GDMT varies by LVEF phenotype and is limited by renal dysfunction and age. Our findings emphasize a high-risk subgroup that may benefit from prospective optimization strategies for post-discharge medical therapy after AMI-CS.RAAS-inhibitor and Beta-blocker Prescription