Timing the bridge in AMI-CS: recovery versus advanced therapies
C Santos Jorge, A Garcia, M Presume, R Gomes, A R Bello, J Presume, J Ferreira, C BrizidoAbstract
Background
Cardiogenic shock (CS) following acute myocardial infarction (AMI) has extremely high mortality despite advances in revascularization and short-term mechanical circulatory support (MCS). The progression to advanced heart failure (HF) requiring heart transplantation (HT) or durable left ventricular assist device (LVAD) represents the ultimate dismal outcome of refractory pump failure. We sought to characterize AMI-CS clinical trajectory and identify predictors of transition to advanced HF therapies.
Methods
Single-center, retrospective study including all consecutive patients admitted with AMI-CS between 2017-2025 to a cardiac intensive care unit. Patients over 70 years old were excluded, as they don’t comply with institutional criteria for advanced HF therapies. Patient data were collected at admission, day 5, and day 30. Although no standard timing defines irreversible pump failure after MI, a 5-day cutoff was used, reflecting our institutional practice for initiating advanced HF therapy evaluation. Patient status at 5 and 30 days was defined as recovered from CS, support-dependent (INTERMACS 3 or worse) or dead. Predictors of 30-day mortality and the need for HT or LVAD during index admission or follow-up were obtained through univariate analysis.
Results
From a total of 200 AMI-CS patients, 112 were included (mean age 59±10 years, 30% women). Most presented in SCAI stage C or D (n=85, 76%), and 24 (21%) presented with cardiac arrest. Median LVEF was 25% (20–35%) and MCS was required in 34 patients (31%). At day 5, 37 patients (33%) had recovered, 44 (38%) were support-dependent, and 31 (28%) had died. By day 30, 47 (42%) had recovered, 9 (8%) remained support-dependent, 50 (45%) had died and 6 (5%) underwent HT or LVAD implantation. Among the support-dependent patients at day 30, 4 underwent HT later during index hospitalization and one after discharge, and the remaining 4 died. Predictors of 30-day mortality included initial and day 5 SCAI stage (p=0.002), cardiac arrest at presentation (p=0,02) and ventricular dysfunction (p=0.016), particularly left ventricular and biventricular dysfunction. The need for advanced HF therapies was predicted by MCS use (p=0.05), longer MCS duration (p=0.016), lower LVEF (p=0.038), support-dependent status at day 5 (p=0,03), and ongoing MCS at day 5 (p=0.03). The type of mechanical circulatory support influenced 30-day outcomes (p <0,001), as patients supported with IABP and Impella had better chances of recovery and survival, while more complex MCS were associated with worse outcomes and greater likelihood of needing HT or LVAD.
Conclusions
AMI-CS patients are a high-risk population with a high mortality rate. Persistent hemodynamic instability, prolonged and more complex MCS, and lower LVEF were the strongest predictors of the need for advanced HF therapies. Early recognition of irreversible myocardial failure is essential to optimize referral and timing for LVAD or transplantation.For image description, please refer to the figure legend and surrounding text.