Surgical Revascularization in Cardiogenic Shock Due to NSTEMI

Background: Cardiogenic shock is a life-threatening complication of sub-endocardial acute myocardial infarction (NSTEMI). Current guidelines recommend emergency revascularization for patients with cardiogenic shock. This study aims to identify risk factors in regards to mortality/ morbidity in surgically treated NSTEMI patients with cardiogenic shock.

Method: We performed a retrospective, single-center, observational analysis. Over the course of 5 years (2016–2020), we identified 590 NSTEMI patients (mean age: 67.6 ± 10.1 years, 20.3% female) requiring surgical revascularization. The study cohort was divided into two groups: group NSTEMI + shock (n = 42), requiring pharmacological or mechanical circulatory support, and group NSTEMI − shock (n = 548).

Results: We identified significant differences between the +shock group and the −shock group regarding left ventricular ejection fraction (LVEF) (34.5 ± 12.8% vs. 47.8 ± 13.1%, p < 0.01), troponin T levels (1,714.2 ± 2,144.0 vs. 748.1 ± 1,485.1 ng/L, p > 0.01), lactate level > 20 mg/dL (38.1 vs. 3.0%, p > 0.01), systemic hypertension (64.9 vs. 88.9%, p < 0.01), and EuroSCORE II (14.1 vs. 4.8%, p < 0.01). Other parameters (including age, gender, syntax score, comorbidities at baseline) and operative characteristics (including length of surgery, cross-clamp time, and number of anastomosis) showed no significant differences.

Major adverse cardiac events occurred significantly more frequently in the +shock group (45.6%) as opposed to the -shock-group (21.5%, p < 0.01). Significant differences occurred for complications such as sepsis (p < 0.01), respiratory failure (p < 0.01), acute renal insufficiency as new need for dialysis (p < 0.01), cardiopulmonary resuscitation (p < 0.01), and gastrointestinal complications (p = 0.01). 40.5% of the shock group had low cardiac output and 23.8% needed mechanical circulatory support.

Overall hospital mortality within the +shock group was higher than in the −shock group (23.8 vs. 4.2%, p < 0.01). Multivariate analysis revealed a trend for lower LVEF as the only independent risk factor (OR 1.08, Cl 1.0–1.16, p = 0.055) for survival in the +shock group, while it was a risk factor in the –shock group (OR 1.06, Cl 1.03–1.09, p < 0.01). Multivariate analysis of the +shock group revealed no significant risk factor for morbidity.

Conclusion: Revascularization of patients with cardiogenic shock due to NSTEMI is associated with increased hospital- mortality and morbidity. NSTEMI-patients in cardiogenic shock with low LVEF are at highest risk and may require temporary mechanical circulatory support.

Publication History

Article published online:
03 February 2022