Contemporary prevalence, trends, and outcomes of coronary chronic total occlusions in acute myocardial infarction with cardiogenic shock

Abstract

Background: There are limited data on the prevalence and outcomes of chronic total occlusions (CTO) of the coronary artery in acute myocardial infarction with cardiogenic shock (AMI-CS) patients.

Methods: Using the National Inpatient Sample, all admissions with AMI-CS that underwent diagnostic angiography between January 1, 2008, and December 31, 2014, were included. CTO, percutaneous coronary intervention (PCI), comorbidities and concomitant cardiac arrest was identified for all admissions. Outcomes of interest included temporal trends, in-hospital mortality, and resource utilization in cohorts with and without CTO.

Results: In this 7-year period, 163,628 admissions with AMI-CS admissions met the inclusion criteria, with 68% being ST-elevation AMI-CS. CTO was noted in 27,343 (16.7%) admissions, with an increase in prevalence during the study period. The cohort with CTOs was more likely to be male and bearing private insurance. The CTO cohort had higher cardiovascular comorbidity, higher rates of cardiac arrest and higher use of PCI and mechanical circulatory support. The presence of a CTO was independently associated with higher in-hospital mortality (adjusted odds ratio 1.20 [95% confidence interval 1.16-1.23]; p < 0.001). The cohort with CTO had lower resource utilization (hospital stay and hospitalization costs) but was discharged more frequently to other hospitals. The presence of a CTO was associated with higher in-hospital mortality in the sub-groups of ST-elevation AMI-CS (31.5% vs. 28.7%; p < 0.001) and non-ST-elevation AMI-CS (24.8% vs. 23.2%; p < 0.001).

Conclusions: In this cohort of AMI-CS admissions that underwent diagnostic angiography, the presence of a CTO identified a higher risk cohort that had higher in-hospital mortality.

Keywords: Cardiogenic shock; Chronic total occlusion; Complex coronary disease; Myocardial infarction; National Inpatient Sample; Outcomes research.

Fig. 1

Prevalence and in-hospital mortality with chronic total occlusions in AMI-CS. Legend: 1A: unadjusted temporal trends in the prevalence of CTO in all AMI-CS, STEMI-CS and NSTEMI-CS; 1B: adjusted temporal trends of CTO in all AMI-CS, STEMI-CS and NSTEMI-CS (referent year 2008)*; 1C: unadjusted temporal trends in the in-hospital mortality in cohorts with and without CTO in AMI-CS; 1D: adjusted temporal trends of in-hospital mortality in cohorts with and without CTO in AMI-CS (referent year 2008)^; all p < 0.001 for trend. *Adjusted for age, sex, race, race, weekend admission, primary payer, socio-economic status, hospital location and teaching status, hospital region, hospital bedsize, comorbidity. ^Adjusted for age, sex, race, race, weekend admission, primary payer, socio-economic status, hospital location and teaching status, hospital region, hospital bedsize, comorbidity, acute organ failure, cardiac arrest, percutaneous coronary intervention, invasive hemodynamic monitoring, mechanical circulatory support, invasive mechanical ventilation, hemodialysis.