Risk, Management, and Outcomes in PCI-Treated Acute Coronary Syndrome With Cardiogenic Shock

Figures

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  Figure 1. Study Flow of PCI-Treated ACS Complicated by Cardiogenic Shock From the KiCS-PCI Registry A total of 24,527 consecutive patients who underwent PCI between 2009 and 2019 were screened. Among 10,053 patients with ACS, 870 with ACS-CS were included in the analytic cohort. ACS = acute coronary syndrome; KiCS-PCI = Keio Interhospital Cardiovascular Studies–Percutaneous Coronary Intervention; PCI = percutaneous coronary intervention.

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  Central Illustration. 10-Year Trends in PCI-Treated Cardiogenic Shock Patients, 2009 to 2019 The figure summarizes the study population and major trends over 10 years among 870 patients with ACS-CS who underwent PCI in the KiCS-PCI registry. PCI-related care changed substantially, and overall MCS utilization decreased, mainly driven by reduced IABP use; VA-ECMO use showed no clear trend across time groups. In-hospital mortality did not significantly improve; crude major bleeding increased over time, but this trend was attenuated after NCDR risk adjustment. Major bleeding was defined according to the NCDR CathPCI Registry definition, as described in the Methods. ACS = acute coronary syndrome; ACS-CS = acute coronary syndrome complicated by cardiogenic shock; IABP = intra-aortic balloon pump; IVUS = intravascular ultrasound; KiCS-PCI = Keio Interhospital Cardiovascular Studies–Percutaneous Coronary Intervention; MCS = mechanical circulatory support; MVD = multivessel disease; NCDR = National Cardiovascular Data Registry; PCI = percutaneous coronary intervention; VA-ECMO = venoarterial extracorporeal membrane oxygenation.

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  Figure 2. 10-Year Trends in Mechanical Circulatory Support Use Annual analysis showed a significant decline in overall MCS use, from 78.3% in 2009 to 56.8% in 2019 (P for trend = 0.026), primarily driven by a reduction in IABP use alone (56.5% to 29.7%; P for trend <0.001). Concomitant use of VA-ECMO and IABP remained relatively stable (21.7% to 21.6%; P for trend = 0.17), whereas overall use of VA-ECMO, with or without IABP, increased significantly (15.9% to 27.0%; P for trend = 0.039). No Impella use was observed during the study period. IABP = intra-aortic balloon pump; MCS =mechanical circulatory support; VA-ECMO = venoarterial extracorporeal membrane oxygenation.

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  Figure 3. 10-Year Trends in Major Bleeding After Percutaneous Coronary Intervention Temporal trends in crude, predicted, and risk-adjusted major bleeding after PCI among patients with ACS-CS are shown by year of PCI. Major bleeding was defined as bleeding within 72 hours after PCI, including access-site bleeding, intracranial hemorrhage, cardiac tamponade, retroperitoneal bleeding, gastrointestinal bleeding, genitourinary bleeding, a hemoglobin decrease of 3 g/dL or greater, or blood transfusion. Although crude bleeding rates increased over time, this trend was attenuated after adjustment using the NCDR CathPCI Bleeding Risk Score.

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  Figure 4. 10-Year Trends in In-Hospital Mortality After Percutaneous Coronary Intervention Temporal trends in crude, predicted, and risk-adjusted in-hospital mortality after PCI among patients with ACS-CS are shown by year of PCI. Predicted mortality risk was estimated using the NCDR CathPCI Risk Score.

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  Figure 5. Adjusted Relative Risk of In-Hospital Mortality by Year Adjusted relative risks of in-hospital mortality for each year were estimated using modified Poisson regression, with 2009 as the reference year. Among 870 patients with ACS-CS, missing data were identified for several covariates, and 44 patients were excluded from this analysis, leaving 826 patients for the final model.