Fibrinolysis vs. Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction Cardiogenic Shock

Figure 1. Study population. Comparative effectiveness study design using retrospective cohort of ST‐segment elevation myocardial infarction (STEMI) cardiogenic shock admissions. *Medically managed admissions were defined as those not receiving coronary angiography, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG).

Figure 2. Trends in the use of fibrinolytics and primary percutaneous coronary intervention (PCI) in ST‐segment elevation myocardial infarction cardiogenic shock (STEMI‐CS). (A) Unadjusted temporal trends of fibrinolytics and primary PCI use in the retrospective cohort of all STEMI‐CS admissions between 2009 and 2017 (P < 0.001 for trend over time)*. (B) Adjusted odds ratio for fibrinolytics and primary PCI use in the retrospective cohort of all STEMI‐CS admissions between 2009 and 2017 (with 2009 as the referent); adjusted for age, sex, race, co‐morbidity, out‐of‐hospital cardiac arrest, primary payer, socio‐economic status, hospital region, hospital location and teaching status, and hospital bed size (P < 0.001 for trend over time)*. (C) Unadjusted temporal trends of subsequent coronary angiography, PCI, and coronary artery bypass grafting (CABG) use in the STEMI‐CS admissions receiving initial fibrinolysis between 2009 and 2017 (P < 0.001 for trend over time). *The temporal trends were generated using the retrospective cohort of all STEMI‐CS admissions.

Figure 3. Trends in in‐hospital mortality in admissions receiving fibrinolytics vs. primary percutaneous coronary intervention (PCI) in ST‐segment elevation myocardial infarction cardiogenic shock (STEMI‐CS). (A) Unadjusted temporal trends of in‐hospital mortality in admissions receiving initial fibrinolysis vs. primary PCI in STEMI‐CS admissions between 2009 and 2017 (P < 0.001 for trend over time). (B) Adjusted odds ratio for of in‐hospital mortality in admissions receiving initial fibrinolysis vs. primary revascularization in STEMI‐CS admissions between 2009 and 2017 (with 2009 as the referent); adjusted for age, sex, race, weekend admission, co‐morbidity, primary payer, socio‐economic status, hospital region, hospital location and teaching status, hospital bed size, out‐of‐hospital cardiac arrest, acute organ failure, complications (vascular, haemorrhagic, and mechanical), pulmonary artery catheterization, mechanical circulatory support, invasive mechanical ventilation, acute haemodialysis, do‐not‐resuscitate status, and palliative care referral (P < 0.001 for trend over time).

Figure 4. Subgroup analyses for in‐hospital mortality in admissions receiving initial fibrinolysis as compared with primary percutaneous coronary intervention (PCI) in ST‐segment elevation myocardial infarction (STEMI) cardiogenic shock. Multivariable adjusted odds ratios (95% confidence intervals)* for in‐hospital mortality in those receiving initial fibrinolysis compared with primary revascularization admissions stratified by age, sex, race, presence of cardiac arrest, hospital location, STEMI location, do‐not‐resuscitate (DNR) status, and palliative care referral. *Adjusted for age, sex, race, primary payer, socio‐economic status, hospital characteristics, co‐morbidities, acute non‐cardiac organ failure, pulmonary artery catheterization, invasive mechanical ventilation, acute haemodialysis, mechanical circulatory support, vascular complications, intracranial haemorrhage, haemorrhagic complications, mechanical complications, palliative care referral, and DNR status.