Early initiation of mechanical circulatory support before PCI did not reduce 30-day mortality compared to late initiation across Impella (RR 0.999), IABP (RR 0.970), and VA-ECMO (RR 1.007) cohorts.
Cohort (n=24,000)
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Does early mechanical circulatory support initiation (before PCI) reduce 30-day mortality in adults with acute myocardial infarction-related cardiogenic shock compared to late initiation (after PCI)?
The timing of mechanical circulatory support initiation (before vs. after PCI) in AMI-related cardiogenic shock does not significantly impact 30-day mortality or major complications.
Abstract Background The optimal timing for initiating mechanical circulatory support (MCS) in acute myocardial infarction (AMI)-related cardiogenic shock (CS) remains uncertain. Early initiation may prevent worsening end-organ hypoperfusion, whereas delayed initiation may reflect progressive clinical decline or delayed recognition of shock. This study evaluated whether early versus late MCS initiation impacts short-term outcomes across intra-aortic balloon pump (IABP), Impella, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support strategies. Methods Using the TriNetX Research Network encompassing 107-112 healthcare organizations, we identified adults (≥18 years) admitted with AMI complicated by CS between 2005 and 2025 who underwent percutaneous coronary intervention (PCI) and subsequently received IABP, Impella, or VA-ECMO. Early MCS was defined as device placement before PCI, and late MCS as initiation after PCI. Propensity score matching (PSM) was performed within each device group to balance demographic and clinical covariates. Results In the Impella cohort, before matching there were 5,739 early and 9,286 late initiations; after PSM, 5,739 matched pairs remained (mean age 71.3 ± 11.7 years, ∼28.3% female). Thirty-day mortality was identical at 33.6% for both groups (risk ratio RR 0.999, 95% CI 0.949-1.052; HR 0.998, 95% CI 0.937-1.063), and all secondary outcomes were neutral. In the IABP cohort, 9,377 early and 9,467 late initiations were identified; after PSM, 9,273 matched pairs remained (mean age 72.8 ± 11.9 years, 32.2% female). Thirty-day mortality was 26.2% versus 27.0% (RR 0.970, 95% CI 0.924-1.017; HR 0.964, 95% CI 0.911-1.019), suggesting a non-significant trend toward improved survival with earlier IABP use. Secondary endpoints, including acute kidney injury requiring dialysis, ischemic stroke, ventricular tachycardia, mechanical ventilation, tracheostomy or PEG placement, and non-variceal upper GI bleeding, were comparable between groups. In the VA-ECMO analysis, after PSM (1,010 early vs 1,010 late), mean age was 65.5 ± 11.6 years with 25.4% female. Thirty-day mortality was 43.9% vs 43.6% (RR 1.007, 95% CI 0.912-1.112; HR 1.006, 95% CI 0.882-1.148), with no differences in secondary outcomes. Conclusion Across more than 24,000 AMI-CS hospitalizations and three MCS modalities, earlier initiation did not reduce 30-day mortality or major complications. Only a minor, non-significant survival signal was seen for early IABP use. These findings suggest that timing alone may not alter short-term outcomes and emphasize the need for prospective studies integrating shock severity, perfusion dynamics, and revascularization strategies into MCS timing algorithms. This abstract is funded by: None
Torres et al. (Fri,) conducted a cohort in Acute myocardial infarction-related cardiogenic shock (n=24,000). Early mechanical circulatory support (before PCI) vs. Late mechanical circulatory support (after PCI) was evaluated on 30-day mortality. Early initiation of mechanical circulatory support before PCI did not reduce 30-day mortality compared to late initiation across Impella (RR 0.999), IABP (RR 0.970), and VA-ECMO (RR 1.007) cohorts.