Elsevier

International Journal of Cardiology

Volume 185, 15 April 2015, Pages 256-262
International Journal of Cardiology

17-year trends in incidence and prognosis of cardiogenic shock in patients with acute myocardial infarction in western Sweden

https://doi.org/10.1016/j.ijcard.2015.03.106Get rights and content

Highlights

  • Sweden has a national system of medical and healthcare quality registries.

  • These contain individualized data on risk factors, diagnoses, interventions and outcome.

  • We present data on 44,414 patients with acute myocardial infarction.

  • 3,654 patients developed cardiogenic shock.

  • Incidence of cardiogenic shock decreased but prognosis worsened over the study period.

Abstract

Background

Cardiogenic shock remains the leading cause of in hospital death in acute myocardial infarction (AMI) and is associated with a mortality rate of approximately 50%. Here we investigated the 17-year trends in incidence and prognosis of AMI-induced cardiogenic shock in Västra Götaland in western Sweden, an area with approximately 1.6 million inhabitants. The study period includes the transition from thrombolysis to primary percutaneous coronary intervention (PCI) as the region-wide therapy of choice for patients with ST-elevation myocardial infarction (STEMI).

Methods

Data on patients hospitalized in cardiac care units in Västra Götaland, Sweden between 1995 and 2013 were obtained from the Swedish Websystem for Enhancement of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). We determined the incidence of cardiogenic shock among patients diagnosed with AMI and the risk of death associated with developing cardiogenic shock. We fitted logistic regression models to study which factors predicted post-AMI cardiogenic shock. Analyses were performed on complete case data as well as after multiple imputation of missing data.

Results

Incidence of cardiogenic shock as a complication of AMI declined in western Sweden in the past decade, from 14% in 1995 to 4% in 2012. The risk of dying once cardiogenic shock had developed increased during the study period (p < 0.01). Patients presenting with STEMI were more likely to develop cardiogenic shock than patients presenting with non STEMI (p < 0.001).

Conclusions

The incidence of cardiogenic shock has declined but cardiogenic shock carries a worse prognosis today than in 1995.

Introduction

Cardiogenic shock remains the leading cause of in hospital death in acute myocardial infarction and is associated with a mortality rate of approximately 50% [1]. Cardiogenic shock may lead to death from hemodynamic deterioration per se or from target organ hypoperfusion with subsequent development of multiorgan dysfunction and/or overt systemic inflammatory syndrome [2], [3]. The incidence of cardiogenic shock in acute myocardial infarction (AMI) has declined in recent decades [4], [5], [6], [7]. This declining trend has been ascribed to early reperfusion strategies, including percutaneous coronary intervention (PCI). Recently, however, a report from an American cohort detected no difference in incidence of cardiogenic shock over the past three decades. If anything, the authors observed a trend towards increasing incidence of cardiogenic shock [8].

PCI, if performed within 90 min after symptom onset, improves prognosis in patients with ST-elevation myocardial infarction (STEMI) and reduces the risk of post-infarct heart failure and cardiogenic shock compared with thrombolysis [9]. International guidelines therefore advocate primary PCI as first-line treatment in patients presenting with STEMI [10], [11].

Sweden has a national system of medical and healthcare quality registries, which contain individualized data concerning diagnoses, interventions and outcome. In the present manuscript, we present the trends in incidence and prognosis of AMI-induced cardiogenic shock from 1995 to 2013 in Västra Götaland in western Sweden, an area with approximately 1.6 million inhabitants who are served by five hospitals. This study period includes the transition from thrombolysis to primary PCI as the region-wide therapy of choice for patients with STEMI.

Section snippets

Methods

The study was approved by the ethics committee of Gothenburg University and adheres to the ethics of scientific publication.

Patient characteristics and treatments

During the study period, 44,414 patients were treated due to AMI in cardiac care units in western Sweden. 3,654 of these patients developed cardiogenic shock (36% women) (Fig. 1). Patient characteristics are presented in Table 1. Patients who developed cardiogenic shock were older and more likely to be women and have diabetes mellitus. They were also more likely to previously have had an AMI and to present with STEMI. On the other hand, patients with cardiogenic shock were less likely to have

Discussion

We investigated the trends in incidence of cardiogenic shock and its impact on mortality in 44,414 patients, 3654 of whom developed cardiogenic shock, in the prospective SWEDHEART database for western Sweden. We found that the incidence of cardiogenic shock declined by 71% over the last seventeen years. The declining incidence of cardiogenic shock was accompanied by a 54% reduction in the overall short-term risk of death for patients with AMI. The steepest decline coincided with the change from

Conclusion

In conclusion, our study demonstrates that the incidence of AMI-induced cardiogenic shock has declined in western Sweden over the past decade. However, once cardiogenic shock develops the mortality is higher today than it was in 1995.

Conflicts of interest

None.

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    Grant support: the study was supported by the Swedish Heart and Lung Foundation (20120670), the Swedish Scientific Research Council (2008-2487), AFA Insurance (110115) and the University of Gothenburg, Sweden (141131).

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