Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock
Mohit Pahuja MD
Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorSagar Ranka MD
Division of Cardiology, Department of Internal Medicine, Kansas University Medical Center, Kansas, Kansas, USA
Search for more papers by this authorOmar Chehab MD, MSc
Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorTushar Mishra MD
Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorEmmanuel Akintoye MD, MPH
Division of Cardiology, Department of Internal Medicine, University of Iowa Medical Center, Iowa, Iowa, USA
Search for more papers by this authorOluwole Adegbala MD, MPH
Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorAhmed S. Yassin MD
Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorTomo Ando MD
Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York, USA
Search for more papers by this authorKatherine L. Thayer MPH
Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
Search for more papers by this authorPalak Shah MD
Division of Cardiology, Inova Heart and Vascular Institute, Fairfax, Virginia, USA
Search for more papers by this authorCarey D. Kimmelstiel MD
Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
Search for more papers by this authorPayam Salehi MD
Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
Search for more papers by this authorCorresponding Author
Navin K. Kapur MD
Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
Correspondence
Dr Navin K. Kapur MD, The Cardiovascular Center, Tufts Medical Center, 800 Washington Street, Boston, MA 02339, USA.
Email: [email protected]
Search for more papers by this authorMohit Pahuja MD
Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorSagar Ranka MD
Division of Cardiology, Department of Internal Medicine, Kansas University Medical Center, Kansas, Kansas, USA
Search for more papers by this authorOmar Chehab MD, MSc
Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorTushar Mishra MD
Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorEmmanuel Akintoye MD, MPH
Division of Cardiology, Department of Internal Medicine, University of Iowa Medical Center, Iowa, Iowa, USA
Search for more papers by this authorOluwole Adegbala MD, MPH
Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorAhmed S. Yassin MD
Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
Search for more papers by this authorTomo Ando MD
Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York, USA
Search for more papers by this authorKatherine L. Thayer MPH
Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
Search for more papers by this authorPalak Shah MD
Division of Cardiology, Inova Heart and Vascular Institute, Fairfax, Virginia, USA
Search for more papers by this authorCarey D. Kimmelstiel MD
Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
Search for more papers by this authorPayam Salehi MD
Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
Search for more papers by this authorCorresponding Author
Navin K. Kapur MD
Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
Correspondence
Dr Navin K. Kapur MD, The Cardiovascular Center, Tufts Medical Center, 800 Washington Street, Boston, MA 02339, USA.
Email: [email protected]
Search for more papers by this authorFunding information: Center for Scientific Review, Grant/Award Number: Funding from NIH 1R01HL139785-01 to Dr. Navin K Ka
Abstract
Background
Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI).
Objective
We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI.
Methods
We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation.
Results
Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs.
Conclusions
Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.
CONFLICT OF INTEREST
N. K. K.: Consulting/Speaker Honoraria and Research Grants from Abbott, Abiomed, Boston Scientific, LivaNova, Medtronic, Maquet, preCARDIA, and MD Start.
Supporting Information
| Filename | Description |
|---|---|
| ccd29003-sup-0001-Tables.docxWord 2007 document , 55.2 KB | Supplementary Table 1 ICD-9 diagnosis and procedural codes Supplementary Table 2: List of Elixhauser comorbidities Supplementary Table 3: Baseline characteristics of patients with and without bleeding complications for patients with no MCS, IABP, PVAD or ECMO. Supplementary Table 4: Baseline characteristics of patients with and without acute limb ischemia for patients with no MCS, IABP, PVAD or ECMO. Supplementary Table 5: Adjusted risk of having an event of bleeding complications and ALI among patients with IABP, PVAD or ECMO in comparison to those with no MCS. Supplementary Table 6: Adjusted adverse event risk by number of transfusions in patients with CS-STEMI and bleeding complications. Supplementary Table 7: Inhospital mortality with and without surgical/endovascular intervention in patients with ALI. |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
REFERENCES
- 1Babaev A, Frederick PD, Pasta DJ, et al. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA. 2005; 294: 448-454.
- 2Jeger RV, Radovanovic D, Hunziker PR, et al. Ten-year trends in the incidence and treatment of cardiogenic shock. Ann Intern Med. 2008; 149: 618-626.
- 3Lo N, Magnus Ohman E. Mechanical Circulatory Support in ST-Elevation Myocardial infarction. In: TJ Watson, PJL Ong, JE Tcheng, eds. Primary Angioplasty: A Practical Guide. Singapore: Springer; 2018: 253-273.
10.1007/978-981-13-1114-7_19 Google Scholar
- 4Backhaus T, Fach A, Schmucker J, et al. Management and predictors of outcome in unselected patients with cardiogenic shock complicating acute ST-segment elevation myocardial infarction: results from the Bremen STEMI registry. Clin Res Cardiol. 2018; 107: 371-379.
- 5Rathod KS, Koganti S, Iqbal MB, et al. Contemporary trends in cardiogenic shock: incidence, intra-aortic balloon pump utilisation and outcomes from the London heart attack group. Eur Heart J Acute Cardiovasc Care. 2018; 7: 16-27.
- 6Thiele H, Ohman EM, de Waha-Thiele S, Zeymer U, Desch S. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J. 2019; 40(32): 2671-2683.
- 7Cheng R, Hachamovitch R, Kittleson M, et al. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg. 2014; 97: 610-616.
- 8Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care (endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; affirmation of value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention). J Card Fail. 2015; 21: 499-518.
- 9Thiele H, Jobs A, Ouweneel DM, et al. Percutaneous short-term active mechanical support devices in cardiogenic shock: a systematic review and collaborative meta-analysis of randomized trials. Eur Heart J. 2017; 38: 3523-3531.
- 10Qian G, Wu C, Chen YD, Tu CC, Wang JW, Qian YA. Predictive factors of cardiac rupture in patients with ST-elevation myocardial infarction. J Zhejiang Univ Sci B. 2014; 15: 1048-1054.
- 11Lambert L, Blais C, Hamel D, et al. Evaluation of care and surveillance of cardiovascular disease: can we trust medico-administrative hospital data? Can J Cardiol. 2012; 28: 162-168.
- 12Redfors B, Watson BM, McAndrew T, et al. Mortality, length of stay, and cost implications of procedural bleeding after percutaneous interventions using large-bore catheters. JAMA Cardiol. 2017; 2: 798-802.
- 13Baril DT, Ghosh K, Rosen AB. Trends in the incidence, treatment, and outcomes of acute lower extremity ischemia in the United States medicare population. J Vasc Surg. 2014; 60: 669-677.
- 14Ando T, Akintoye E, Uemura T, et al. Palliative care referral in ST-segment elevation myocardial infarction complicated with cardiogenic shock in the United States. Heart Lung. 2020; 49: 25-29.
- 15Pahuja M, Adegbala O, Mishra T, et al. Trends in the incidence of in-hospital mortality, cardiogenic shock, and utilization of mechanical circulatory support devices in myocarditis (analysis of national inpatient sample data, 2005-2014). J Card Fail. 2019; 25: 457-467.
- 16Wayangankar SA, Bangalore S, McCoy LA, et al. Temporal trends and outcomes of patients undergoing percutaneous coronary interventions for cardiogenic shock in the setting of acute myocardial infarction: a report from the CathPCI registry. JACC Cardiovasc Interv. 2016; 9: 341-351.
- 17Kar B, Gregoric ID, Basra SS, Idelchik GM, Loyalka P. The percutaneous ventricular assist device in severe refractory cardiogenic shock. J Am Coll Cardiol. 2011; 57: 688-696.
- 18Sjauw KD, Engstrom AE, Vis MM, et al. A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines? Eur Heart J. 2009; 30: 459-468.
- 19Thiele H, Sick P, Boudriot E, et al. Randomized comparison of intra-aortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. Eur Heart J. 2005; 26: 1276-1283.
- 20Stretch R, Sauer CM, Yuh DD, Bonde P. National trends in the utilization of short-term mechanical circulatory support: incidence, outcomes, and cost analysis. J Am Coll Cardiol. 2014; 64: 1407-1415.
- 21Bundhun PK, Janoo G, Chen MH. Bleeding events associated with fibrinolytic therapy and primary percutaneous coronary intervention in patients with STEMI: a systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2016; 95:e3877.
- 22Fox KA, Carruthers K, Steg PG, et al. Has the frequency of bleeding changed over time for patients presenting with an acute coronary syndrome? The global registry of acute coronary events. Eur Heart J. 2010; 31: 667-675.
- 23Steg PG, Huber K, Andreotti F, et al. Bleeding in acute coronary syndromes and percutaneous coronary interventions: position paper by the working group on thrombosis of the European Society of Cardiology. Eur Heart J. 2011; 32: 1854-1864.
- 24Wu WC, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med. 2001; 345: 1230-1236.
- 25Boden H, Velders MA, van der Hoeven BL, Cannegieter SC, Schalij MJ. In-hospital major bleeding and its clinical relevance in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention. Am J Cardiol. 2013; 112: 1533-1539.
- 26Cohen M. Predictors of bleeding risk and long-term mortality in patients with acute coronary syndromes. Curr Med Res Opin. 2005; 21: 439-445.
- 27Giugliano RP, Giraldez RR, Morrow DA, et al. Relations between bleeding and outcomes in patients with ST-elevation myocardial infarction in the ExTRACT-TIMI 25 trial. Eur Heart J. 2010; 31: 2103-2110.
- 28Kikkert WJ, Zwinderman AH, Vis MM, et al. Timing of mortality after severe bleeding and recurrent myocardial infarction in patients with ST-segment-elevation myocardial infarction. Circ Cardiovasc Interv. 2013; 6: 391-398.
- 29O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2013; 61: 485-510.
- 30Numasawa Y, Kohsaka S, Ueda I, et al. Incidence and predictors of bleeding complications after percutaneous coronary intervention. J Cardiol. 2017; 69: 272-279.
- 31Miller PE, Solomon MA, McAreavey D. Advanced percutaneous mechanical circulatory support devices for cardiogenic shock. Crit Care Med. 2017; 45: 1922-1929.
- 32Kapur NK, Alkhouli MA, DeMartini TJ, et al. Unloading the left ventricle before reperfusion in patients with anterior ST-segment-elevation myocardial infarction. Circulation. 2019; 139: 337-346.
- 33Kapur NK, Hirst C, Zisa D. Advances in vascular post-closure with Impella. Cardiovasc Revasc Med. 2019; 20: 94-95.
- 34Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA. 2004; 292: 1555-1562.
- 35Corwin HL, Gettinger A, Pearl RG, et al. The CRIT study: anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med. 2004; 32: 39-52.
- 36Gili S, D'Ascenzo F, Lococo MF, et al. Impact of blood transfusion on in-hospital myocardial infarctions according to patterns of acute coronary syndrome: insights from the BleeMACS registry. Int J Cardiol. 2016; 221: 364-370.
- 37Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation. 2007; 116: 2544-2552.
- 38Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009; 361: 2241-2251.
- 39Kovacic JC, Nguyen HT, Karajgikar R, Sharma SK, Kini AS. The Impella recover 2.5 and TandemHeart ventricular assist devices are safe and associated with equivalent clinical outcomes in patients undergoing high-risk percutaneous coronary intervention. Catheter Cardiovasc Interv. 2013; 82: E28-E37.
- 40Sjauw KD, Konorza T, Erbel R, et al. Supported high-risk percutaneous coronary intervention with the Impella 2.5 device the Europella registry. J Am Coll Cardiol. 2009; 54: 2430-2434.
- 41Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012; 367: 1287-1296.
- 42O'Neill WW, Schreiber T, Wohns DH, et al. The current use of Impella 2.5 in acute myocardial infarction complicated by cardiogenic shock: results from the USpella registry. J Interv Cardiol. 2014; 27: 1-11.
- 43Saw J, Bhatt DL, Moliterno DJ, et al. The influence of peripheral arterial disease on outcomes: a pooled analysis of mortality in eight large randomized percutaneous coronary intervention trials. J Am Coll Cardiol. 2006; 48: 1567-1572.
- 44Hatch J, Baklanov D. Percutaneous hemodynamic support in PCI. Curr Treat Options Cardiovasc Med. 2014; 16: 293.
- 45Abaunza M, Kabbani LS, Nypaver T, et al. Incidence and prognosis of vascular complications after percutaneous placement of left ventricular assist device. J Vasc Surg. 2015; 62: 417-423.
- 46Sklar MC, Sy E, Lequier L, Fan E, Kanji HD. Anticoagulation practices during venovenous extracorporeal membrane oxygenation for respiratory failure. A systematic review. Ann Am Thorac Soc. 2016; 13: 2242-2250.
- 47Thiele H, Lauer B, Hambrecht R, Boudriot E, Cohen HA, Schuler G. Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance. Circulation. 2001; 104: 2917-2922.
- 48Sarrazin MS, Rosenthal GE. Finding pure and simple truths with administrative data. JAMA. 2012; 307: 1433-1435.
