Acute Noncardiac Organ Failure in Acute Myocardial Infarction With Cardiogenic Shock
Key result
Noncardiac multiorgan failure in AMI-CS is linked to ~2.2-fold higher in-hospital mortality.
- OR 2.23
- 95% CI 2.19-2.27
- n=444,253
Why the study?
Data on the national trends, resource utilization, and outcomes of acute noncardiac single and multiorgan failure in cardiogenic shock complicating acute myocardial infarction (AMI-CS) were limited.
Does the presence of single or multiple noncardiac organ failures increase in-hospital mortality and resource utilization in patients with acute myocardial infarction complicated by cardiogenic shock?
Key Points
- To assess 15-year temporal trends, resource utilization, and in-hospital mortality associated with single and multiple acute noncardiac organ failures in acute myocardial infarction complicated by cardiogenic shock.
- Retrospective cohort study evaluating 444,253 admissions for acute myocardial infarction with cardiogenic shock from the National Inpatient Sample database between 2000 and 2014.
- Identified respiratory, renal, hepatic, hematologic, and neurological failures using validated diagnosis codes to classify single versus multiorgan (≥2 organ systems) failure.
- Single-organ noncardiac failure occurred in 32.4% and multiorgan failure in 31.9% of admissions, with the prevalence of both increasing steadily over time.
- Single-organ failure (odds ratio: 1.28; 95% confidence interval: 1.26 to 1.30) and multiorgan failure (odds ratio: 2.23; 95% confidence interval: 2.19 to 2.27) were independently associated with higher in-hospital mortality, increased resource utilization, and fewer home discharges.
- Patients with multiorgan failure received coronary angiography and revascularization less frequently, and mortality increased in a stepwise fashion with each additional failing organ system.
Study Design
Type
Cohort (n=444,253)
Multicenter
Yes
Structured PICO
Does the presence of single or multiple noncardiac organ failures increase in-hospital mortality and resource utilization in patients with acute myocardial infarction complicated by cardiogenic shock?
P
Population
444,253 inpatient admissions with cardiogenic shock complicating acute myocardial infarction from the National Inpatient Sample database between 2000 and 2014.
E
Exposure
Presence of single or multiorgan (≥2 organ systems: respiratory, renal, hepatic, hematologic, and neurological) noncardiac organ failure
C
Comparator
Absence of noncardiac organ failure in AMI-CS admissions
O
Outcome
In-hospital mortalityhard clinical
Main Result
Odds Ratio: 2.23 (95% CI 2.19–2.27)
In AMI-CS admissions, noncardiac multiorgan failure has steadily increased in prevalence and is independently associated with a more than twofold increase in in-hospital mortality and greater resource utilization.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“In many of the shock states, like septic shock or postcardiotomy shock, it’s very well established, but there is limited data with cardiogenic shock. For the longest time as cardiologists, we believed the problem was the coronaries and if we fix the coronaries these patients will get better. Unfortunately, nearly 45% of patients who have their coronaries fixed and have normal central hemodynamics still die. So clearly there is an additional insult in the form of microcirculatory abnormalities.”
“The unknown here, which we have been trying to address clinically in our system, is: how much of this mortality and morbidity is preventable by earlier detection and earlier therapy and how much is nonpreventable death? Death is more likely to be nonpreventable once patients manifest with multiorgan failure.”
Implication
May signal need for multiorgan assessment in AMI shock; leaves open optimal interventions for prospective study.
Abstract
Background There are limited data on acute noncardiac multiorgan failure in cardiogenic shock complicating acute myocardial infarction (AMI-CS). Objectives The authors sought to evaluate the 15-year national trends, resource utilization, and outcomes of single and multiple noncardiac organ failures in AMI-CS. Methods This was a retrospective cohort study of AMI-CS using the National Inpatient Sample database from 2000 to 2014. Previously validated codes for respiratory, renal, hepatic, hematologic, and neurological failure were used to identify single or multiorgan (≥2 organ systems) noncardiac organ failure. Outcomes of interest were in-hospital mortality, temporal trends, and resource utilization. The effects of every additional organ failure on in-hospital mortality and resource utilization were assessed. Results In 444,253 AMI-CS admissions, noncardiac single or multiorgan failure was noted in 32.4% and 31.9%, respectively. Multiorgan failure was seen more commonly in admissions with non-ST-segment elevation AMI-CS, nonwhite race, and higher baseline comorbidity. There was a steady increase in the prevalence of single and multiorgan failure. Coronary angiography and revascularization were performed less commonly in multiorgan failure. Single-organ failure (odds ratio: 1.28; 95% confidence interval: 1.26 to 1.30) and multiorgan failure (odds ratio: 2.23; 95% confidence interval: 2.19 to 2.27) were independently associated with higher in-hospital mortality, greater resource utilization, and fewer discharges to home. There was a stepwise increase in in-hospital mortality and resource utilization with each additional organ failure. Conclusions There has been a steady increase in the prevalence of multiorgan failure in AMI-CS. Presence of multiorgan failure was independently associated with higher in-hospital mortality and greater resource utilization.
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Cite This Study
Vallabhajosyula et al. (2019) conducted a cohort in Cardiogenic shock complicating acute myocardial infarction (AMI-CS) (n=444,253). Noncardiac multiorgan failure (≥2 organ systems) vs. No noncardiac organ failure was evaluated on In-hospital mortality (OR 2.23, 95% CI 2.19-2.27). Noncardiac single-organ (OR 1.28; 95% CI 1.26-1.30) and multiorgan failure (OR 2.23; 95% CI 2.19-2.27) in AMI-CS were independently associated with higher in-hospital mortality.