Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

BackgroundDespite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated.MethodsWe analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality.ResultsAmong 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, P-<-0.01). Considering data available at FMC, CS patients with a combination of age ≥76-years, anterior STEMI and an expected ischemia time > 3-h and 21-min were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045-1,141; P-=-0.003), final TIMI flow 2-3 (OR 0.058; 95% CI 0.004-0.785; P-=-0.032) and Ischemia Time (OR-=-1.269; 95% CI 1.001-1.609; P-=-0.049) were independently associated with 30-day mortality.ConclusionsIn a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.