Shock Timing in STEMI-CS

Q: What are the key findings of this study?

Cardiogenic shock onset prior to arrival at a reperfusion center was not statistically significantly associated with higher in-hospital mortality compared to onset after arrival in a multivariable model.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Cardiogenic shock complicating STEMI (STEMI-CS) (n=435). Intervention: Shock prior to arrival at reperfusion center (PRC) vs. Shock after arrival at reperfusion center (ARC). Primary outcome: In-hospital mortality (OR 1.65, 95% CI 0.86-3.18, p=0.13).

Q: What does this research mean for the field?

In STEMI-complicated cardiogenic shock, shock onset prior to arrival at a reperfusion center is not independently associated with increased in-hospital mortality compared with onset after arrival after multivariable adjustment. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Luis Enrique Remedios Carbonell; Mariaydis Perez Reyes; Dayani Arteaga-Guerra; Maidelis Prieto Guerra; Geovedy Martínez García; Maikel Santos Medina; Leonardo A Almaguer Gongora; Bernardo Reyes; Miguel Rodríguez Ramos

doi:10.1016/j.jacadv.2026.103179

September 1, 2026JACC AdvancesOpen Access

Shock Timing in STEMI-CS

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Key result

Pre-arrival cardiogenic shock onset is not associated with higher in-hospital mortality versus post-arrival onset.

OR 1.65
95% CI 0.86-3.18
P=0.13
n=435

Figures

Graphical abstract published by JACC Advances — Graphical abstract · Published by JACC Advances · CC BY

Why the study?

Cardiogenic shock complicating STEMI carries high in-hospital mortality, but evidence from low- and middle-income countries remains limited.

Does cardiogenic shock onset prior to arrival compared to after arrival increase in-hospital mortality in patients with STEMI-CS in a resource-limited setting?

Key Points

To compare clinical presentation, medical therapy use, and in-hospital outcomes between patients who develop cardiogenic shock before versus after arrival at a reperfusion center.
Retrospective cohort analysis of the RECUIMA multicenter registry evaluating patients with STEMI admitted to 4 Cuban hospitals.
Identified 435 patients with cardiogenic shock, categorizing them into shock onset prior to arrival at a reperfusion center (PRC, n=134) or after arrival at a reperfusion center (ARC, n=301).
Assessed quality-of-care measures and used multivariable logistic regression to analyze the association between shock timing and in-hospital mortality.
Inpatient best available medical therapy was received less frequently by PRC patients than ARC patients (32.8% vs 51.8%; RR: 0.63; 95% CI: 0.49-0.83; P < 0.001), including lower streptokinase use (38.8% vs 59.5%; RR: 0.65; 95% CI: 0.52-0.82; P < 0.001).
PRC patients presented with worse clinical status, including lower median systolic blood pressure (80 vs 110 mm Hg; P < 0.001), lower median LVEF (38% vs 43%; P < 0.001), and higher GRACE scores (median 129 vs 121; P < 0.001).

Study Design

Type

Cohort (n=435)

Multicenter

Yes

Structured PICO

Does cardiogenic shock onset prior to arrival compared to after arrival increase in-hospital mortality in patients with STEMI-CS in a resource-limited setting?

P

Population

435 adults with STEMI complicated by cardiogenic shock in a multicenter Cuban registry, evaluating outcomes based on pre- vs post-arrival shock onset.

E

Exposure

Cardiogenic shock onset prior to arrival at a reperfusion center (PRC)

C

Comparator

Cardiogenic shock onset after arrival at a reperfusion center (ARC)

O

Outcome

In-hospital mortalityhard clinical

Main Result

Odds Ratio: 1.65 (95% CI 0.86–3.18)

Absolute Event Rate: 50% vs 38.2%

p-value: p=0.13

This observational cohort reveals that STEMI patients presenting with cardiogenic shock prior to hospital arrival exhibit greater clinical severity and receive fewer optimal therapies than those developing shock post-arrival, emphasizing the need for early recognition and faster transport.

Limitations

Observational design limits the ability to establish causal relationships.
Reperfusion strategy based primarily on fibrinolytic therapy may not fully generalize to high-income settings with universal primary PCI.
Unmeasured confounding regarding best available medical therapy (BAMT) administration.
Potential survivor bias for discharge medical therapy prescription rates.
Survival-to-admission bias as prehospital deaths were not captured.
Observational design limits causal inferences.
Reperfusion strategy primarily based on fibrinolytic therapy.
Potential unmeasured confounding in medical therapy selection.
Survivor bias for discharge treatments.
Survival-to-admission bias due to missing prehospital deaths.

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Implication

Prehospital shock onset was not independently associated with mortality; hypothesis-generating for therapy gaps and transport in resource-limited STEMI-CS.

Abstract

BACKGROUND: Cardiogenic shock complicating ST-segment elevation myocardial infarction (STEMI) carries high in-hospital mortality, but evidence from low- and middle-income countries remains limited. OBJECTIVES: The objective of the study was to compare clinical presentation, pharmacological treatment use, and in-hospital outcomes according to shock onset before vs after arrival at a reperfusion center (ARC). METHODS: We performed a retrospective cohort analysis with data from RECUIMA, a multicenter registry of patients with STEMI admitted to 4 Cuban hospitals. Patients with cardiogenic shock complicating STEMI were classified as having shock prior to arrival at a reperfusion center (PRC) or ARC. Multivariable logistic regression assessed the association between shock timing and in-hospital mortality. RESULTS: Among 4,113 patients with STEMI, 435 (10.6%) developed cardiogenic shock; 134 (30.8%) were PRC and 301 (69.2%) ARC. PRC patients had greater clinical severity, including lower systolic blood pressure and left ventricular ejection fraction, worse renal function, and higher Global Registry of Acute Coronary Events scores (all P < 0.01). Inpatient best available medical therapy was less frequent in PRC than ARC patients (32.8% vs 51.8%; relative risk: 0.63; 95% CI: 0.49-0.83; P < 0.001). Unadjusted mortality was higher in PRC patients (50.0% vs 38.2%; relative risk: 1.31; 95% CI: 1.05-1.63; P = 0.021). In the multivariable logistic regression model, shock timing was not statistically significantly associated with mortality (OR: 1.65; 95% CI: 0.86-3.18; P = 0.13). CONCLUSIONS: PRC patients presented with greater severity, received less inpatient best available medical therapy, and had higher unadjusted mortality. However, in the multivariable logistic regression model, shock timing was not statistically significantly associated with mortality.

Discussion

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Cite This Study

Carbonell et al. (2026) conducted a cohort in Cardiogenic shock complicating STEMI (STEMI-CS) (n=435). Shock prior to arrival at reperfusion center (PRC) vs. Shock after arrival at reperfusion center (ARC) was evaluated on In-hospital mortality (OR 1.65, 95% CI 0.86-3.18, p=0.13). Cardiogenic shock onset prior to arrival at a reperfusion center was not statistically significantly associated with higher in-hospital mortality compared to onset after arrival in a multivariable model.

synapsesocial.com/papers/6ad0fd403afa093ea9ad0341 https://doi.org/10.1016/j.jacadv.2026.103179

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Shock Timing in STEMI-CS

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Shock Timing in STEMI-CS

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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