Sex-specific utilization patterns of advanced therapies in MI-related cardiogenic shock : a five year US National Analysis

Background Sex-based differences in the management of myocardial infarction complicated by cardiogenic shock remain a concern, particularly with respect to the use of advanced mechanical therapies. Whether these differences persist after accounting for frailty and illness severity is not well defined. Methods Using data from the National Inpatient Sample (2018–2022), we identified adult hospitalizations for myocardial infarction complicated by cardiogenic shock through specific ICD-10 codes. Primary exposures were sex and frailty burden, with frailty categorized as non-frail, mild, moderate, or severe based on the presence of malnutrition, dementia, pressure ulcers, debility, falls/gait disorders, and sarcopenia, each defined by relevant ICD-10 codes. Outcomes included the use of mechanical circulatory support (MCS) devices—namely intra-aortic balloon pump (IABP), Impella, extracorporeal membrane oxygenation (ECMO), and left ventricular assist device (LVAD)—and in-hospital mortality, identified via procedure codes. Survey-weighted multivariable logistic regression adjusted for demographics, Elixhauser comorbidity burden, illness severity, and hospital characteristics, with testing for sex–frailty interaction. Results In a survey-weighted analysis of patients with MI-related cardiogenic shock, MCS was utilized in 31% of patients, predominantly driven by IABP use. Significant disparities in MCS utilization were observed across sex, race, insurance status, socioeconomic status, and geographic location. Women received MCS less frequently than men (27.9% vs. 33.0%). After multivariable adjustment, female sex was independently associated with lower odds of receiving any MCS ( 0.73, 0.69–0.77, p<0.001), with consistent findings across all MCS modalities, including IABP, Impella, ECMO, and LVAD. Racial disparities were evident, with Black patients showing markedly lower adjusted odds of receiving MCS compared to White patients (0.54, 0.51–0.57, p<0.001). Insurance status and socioeconomic factors also influenced MCS use; private insurance was associated with higher odds of MCS receipt (1.31, 1.23–1.40, p<0.001), and higher income quartiles correlated with modestly increased utilization. Stratification by frailty demonstrated that women consistently had lower predicted probabilities of MCS use across all frailty categories, from non-frail to severely frail. Despite lower MCS utilization, women experienced higher adjusted odds of in-hospital mortality (aOR 1.13, 95% CI 1.07–1.19, p<0.001) and the composite outcome of death or non-home discharge (aOR 1.33, 95% CI 1.25–1.41, p<0.001), underscoring persistent inequities in advanced cardiac care outcomes. Conclusion This study highlights key disparities in MCS use for MI-related cardiogenic shock, with lower use in women, Black patients, and disadvantaged groups, alongside worse outcomes in women. Addressing these inequities is essential to improving care.