Rapid deterioration of SCAI-CS stages in STEMI patients presenting CS stage A/B at ER: Its clinical implication and predictive risk score

Introduction Cardiogenic shock is a dynamic and hemodynamically heterogenous condition in the setting of acute myocardial infarction (AMI). The Society of Cardiovascular Angiography and Intervention cardiogenic shock (SCAI-CS) stages represent 5 different status of CS according to clinical, physical and hemodynamic features. SCAI-CS stage A and B have been considered as initial stages of CS which do not necessarily require intensive management. However, given that CS could be progressive, its stage may rapidly deteriorate after the arrival of AMI patients at ER. However, the frequency, clinical characteristics and outcomes of AMI patients presenting rapid deterioration of SCAI-CS stages at ER remain to be fully elucidated yet. Purpose The current study sought to characterize AMI patients with SCAI-CS stage A/B who rapidly deteriorated to stage C-E after their arrival at ER. Methods We retrospectively analyzed 648 STEMI patients who presented SCAI stage A/B on their arrival. Rapid deterioration of SCAI-CS stages (RD-CS) was defined as those exhibiting SCAI-CS stage C-E after their arrival at ER and before conducting emergent coronary angiography. Clinical characteristics and all-cause mortality were compared between those with and without RD-CS. Multivariate regression analysis was conducted to identify predictors of RD-CS. Results In the current study, 11.2% (=73/648) of study subjects exhibited RD-CS. STEMI patients with RD-CS exhibited lower systolic blood pressure (141.6±27.7 vs. 128.0±33.5 mmHg, p<0.001) and a higher heart rate (76.8±17.8 vs. 86.0±27.0 bpm, p<0.001) compared to those without RD-CS (Table 1). Furthermore, lower levels of LVEF (49.0±9.9 vs. 38.2±13.0%, p<0.001) and base excess (-0.4±3.2 vs. -4.1±6.0 mmol/L, p<0.001) were observed in those with RD-CS (Table 1). During the observational period, RD-CS was associated with a higher all-cause mortality (log-rank p<0.001) (Figure 1). Multivariate analysis revealed systolic blood pressure, heart rate, LVEF and base excess as independent predictors of RD-CS (Table 2). ROC curve analysis identified optimal cut-off values to predict RD-CS (systolic blood pressure<125 mmHg, heart rate>95 bpm, LVEF<40%, base excess<-3.3 mmol/L). Of note, an increasing number of these features was associated with a greater risk of RD-CS (p-value<0.001 for trend, Figure 2). In particular, the frequency of RD-CS rose to 75% in STEMI patients presenting all of these features. Conclusion RD-CS occurred in 11.2% of STEMI patients presenting SCAI-CS stage A/B on their arrival at ER. Systolic blood pressure, heart rate, LVEF and base excess were independent clinical features associated with an elevated risk of RD-CS. Since RD-CS presents a higher all-cause mortality, our findings indicate the importance to evaluate a risk of RD-CS and then select appropriate anti-CS management in STEMI patients who exhibited SCAI-CS stage A/B at ER.Table1/Figure1 Table2/Figure2