Treatment of Acute Myocardial Infarction and Cardiogenic Shock: Outcomes of the RECOVER III Post-Approval Study by SCAI Shock Stage

Background The Society for Cardiovascular Angiography and Interventions (SCAI) proposed a staging system (A-E) to predict prognosis in cardiogenic shock. Herein, we report clinical outcomes of the RECOVER III study for the first time, according to SCAI shock classification. Methods RECOVER III is an observational, prospective, multicenter, single-arm, post-approval study of patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) undergoing percutaneous coronary intervention (PCI) with Impella support. Patients enrolled in RECOVER III were assigned a baseline SCAI shock stage. Staging was then repeated within 24 hours after initiation of Impella. Kaplan-Meier survival curve analyses were conducted to assess survival across SCAI shock stages at both timepoints. Results At baseline assessment, 16.5%, 11.4%, and 72.2% were classified as Stage C, D, and E, respectively. At ≤24 hour assessment, 26.4%, 33.2%, and 40.0% were Stage C, D, and E respectively. Thirty-day survival amongst patients with Stage C, D and E shock at baseline was 59.7%, 56.5% and 42.9%, respectively (p=0.003). Survival amongst patients with Stage C, D and E shock at ≤24 hours was 65.7%, 52.1% and 29.5%, respectively (p<0.001). After multivariate analysis of impact of shock stage classifications at baseline and ≤ 24 hours, only Stage E classification at ≤24 hours was a significant predictor of mortality (OR 4.8, p<0.001). Conclusions In a real-world cohort of patients with AMICS undergoing PCI with Impella support, only Stage E classification at ≤ 24 hours was significantly predictive of mortality, suggesting that response to therapy may be more important than clinical severity of shock at presentation. Clinical Perspective Many patients with AMICS treated with Impella present in SCAI Stage E shock, but may improve to a more favorable shock stage within 24 hours of their presentation. In-hospital and 30-day outcomes correlate with SCAI shock stage at presentation, but the correlation is more robust upon repeat assessment within 24 hours after Impella initiation. The SCAI shock staging system may be a useful clinical tool to guide in-hospital management of patients with AMICS, especially within the first 24 hours, and to provide prognostic information to patients and/or their families.