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. 2022 Apr 5;79(13):1223-1235.
doi: 10.1016/j.jacc.2022.01.037.

Outcomes Associated With Peripheral Artery Disease in Myocardial Infarction With Cardiogenic Shock

Nino Mihatov  1 , Ramya C Mosarla  2 , Ajay J Kirtane  3 , Sahil A Parikh  3 , Kenneth Rosenfield  4 , Siyan Chen  5 , Yang Song  5 , Robert W Yeh  5 , Eric A Secemsky  6
Affiliations

Outcomes Associated With Peripheral Artery Disease in Myocardial Infarction With Cardiogenic Shock

Nino Mihatov et al. J Am Coll Cardiol. .

Abstract

Background: Mortality rates for patients presenting with acute myocardial infarction (AMI) and cardiogenic shock (CS) remain high despite advances in revascularization strategies and mechanical circulatory support (MCS) devices.

Objectives: This study sought to elucidate the association between comorbid lower extremity peripheral artery disease (PAD) and outcomes in CS and AMI.

Methods: PAD status was defined in Medicare beneficiaries hospitalized with CS and AMI from October 1, 2015 to June 30, 2018. Primary outcomes ascertained through December 31, 2018 included in- and out-of-hospital mortality. Secondary outcomes included bleeding, amputation, stroke, and lower extremity revascularization. Multivariable regression models with adjustment for confounders were used to estimate risk. Subgroup analyses included patients treated with MCS and those who underwent coronary revascularization.

Results: Among 71,690 patients, 5.9% (N = 4,259) had PAD. Mean age was 77.8 ± 7.9 years, 58.7% were male, and 84.3% were White. Cumulative in-hospital mortality was 47.2%, with greater risk among those with PAD (56.3% vs 46.6% without PAD; adjusted OR: 1.50; 95% CI: 1.40-1.59). PAD patients also had greater risk of in-hospital amputation (1.6% vs 0.2%; adjusted OR: 7.0; 95% CI: 5.26-9.37) and out-of-hospital mortality (67.9% vs 40.7%; adjusted HR: 1.78; 95% CI: 1.67-1.90). MCS was less frequently utilized in PAD patients (21.5% vs 38.6% without PAD; P < 0.001) and was associated with higher mortality, need for lower extremity revascularization, and amputation risk. Findings were consistent in patients who underwent coronary revascularization.

Conclusions: Among patients presenting with AMI and CS, PAD was associated with worse limb outcomes and survival. In addition to lower MCS utilization rates, those with PAD who received MCS had increased mortality, lower extremity revascularization, and amputation rates.

Keywords: cardiogenic shock; coronary artery bypass grafting; mechanical circulatory support; myocardial infarction; percutaneous coronary intervention; peripheral artery disease.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Mihatov has been funded by National Institutes of Health (NIH) grant T32HL007208. Dr Kirtane has received funding for research grants, speaking engagements and/or consulting paid to his institutions from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, and ReCor Medical; and has received personal fees for travel expenses/meals from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regeneron. Dr Parikh has received institutional research support from Abbott Vascular, TriReme Medical, SurModics, and Shockwave Medical; is an advisory board member for Abbott Vascular, Boston Scientific, Cardinal Health, Medtronic, Janssen, CSI, and Philips; and receives honoraria from Abiomed and Terumo. Dr Rosenfield has served as a consultant to or on the scientific advisory board for Access Vascular, Althea Medical, Angiodynamics, BMS-Pfizer, Boston Scientific, Contego, Janssen, InspireMD, Magneto, Mayo Clinic, Neptune Medical, Philips, Summa Therapeutics, Surmodics, Thrombolex, Terumo, and Truvic; has received institutional grants from the NIH, Philips, Intact Vascular, and Boston Scientific; has equity in Accolade, Access Vascular, Althea Medical, Contego, Cruzar Systems, Embolitech, Endospan, Eximo, InspireMG, JanaCare, Magneto, Micell, Neptune Medical, Orchestra, PQ Bypass, Prosomnus, Shockwave, Summa Therapeutics, Thrombolex, Truvic, and Valcare; and serves as a board member for the National PERT Consortium. Dr Yeh has served on scientific advisory boards, consulted for, and received research support from Abbott Vascular, AstraZeneca, Boston Scientific, and Medtronic; and receives funding from the National Heart, Lung, and Blood Institute grant R01HL136708 and the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology. Dr Secemsky has received consulting and/or speaking fees from Bard, Cook Medical, CSI, Medtronic, and Phillips; and receives research support from NIH/NHLBI K23HL150290, Food & Drug Administration, Harvard Medical School’s Shore Faculty Development Award, AstraZeneca, Bard, Boston Scientific, Cook Medical, CSI, Laminate Medical, Medtronic, and Philips. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1:
Figure 1:. Risk of In-hospital Outcomes in Patients with PAD
Adjusted odds ratios for in hospital events for patients with versus without lower extremity peripheral arterial disease (PAD). [CVA/TIA: Cerebrovascular accident/transient ischemic attack]
Figure 2:
Figure 2:. Risk of Out-of-Hospital Outcomes in Patients with PAD
Cumulative incidence curves and hazard ratios for out-of-hospital outcomes stratified by the presence of lower extremity peripheral artery disease (PAD): a.) Out-of-hospital mortality, b.) Hospitalization for myocardial infarction (MI), c.) Hospitalization for heart failure (HF), and d.) Readmission. For out-of-hospital mortality, cumulative incidence curves estimated using Kaplan Meier methods are displayed. For non-death-related outcomes, cumulative incidence function curves are displayed, which account for the competing risk of death. In addition, all hazard ratios for non-death outcomes are based on sub-distribution hazards models using Fine-Gray methods to account for the competing risk of death.
Figure 2:
Figure 2:. Risk of Out-of-Hospital Outcomes in Patients with PAD
Cumulative incidence curves and hazard ratios for out-of-hospital outcomes stratified by the presence of lower extremity peripheral artery disease (PAD): a.) Out-of-hospital mortality, b.) Hospitalization for myocardial infarction (MI), c.) Hospitalization for heart failure (HF), and d.) Readmission. For out-of-hospital mortality, cumulative incidence curves estimated using Kaplan Meier methods are displayed. For non-death-related outcomes, cumulative incidence function curves are displayed, which account for the competing risk of death. In addition, all hazard ratios for non-death outcomes are based on sub-distribution hazards models using Fine-Gray methods to account for the competing risk of death.
Figure 2:
Figure 2:. Risk of Out-of-Hospital Outcomes in Patients with PAD
Cumulative incidence curves and hazard ratios for out-of-hospital outcomes stratified by the presence of lower extremity peripheral artery disease (PAD): a.) Out-of-hospital mortality, b.) Hospitalization for myocardial infarction (MI), c.) Hospitalization for heart failure (HF), and d.) Readmission. For out-of-hospital mortality, cumulative incidence curves estimated using Kaplan Meier methods are displayed. For non-death-related outcomes, cumulative incidence function curves are displayed, which account for the competing risk of death. In addition, all hazard ratios for non-death outcomes are based on sub-distribution hazards models using Fine-Gray methods to account for the competing risk of death.
Figure 2:
Figure 2:. Risk of Out-of-Hospital Outcomes in Patients with PAD
Cumulative incidence curves and hazard ratios for out-of-hospital outcomes stratified by the presence of lower extremity peripheral artery disease (PAD): a.) Out-of-hospital mortality, b.) Hospitalization for myocardial infarction (MI), c.) Hospitalization for heart failure (HF), and d.) Readmission. For out-of-hospital mortality, cumulative incidence curves estimated using Kaplan Meier methods are displayed. For non-death-related outcomes, cumulative incidence function curves are displayed, which account for the competing risk of death. In addition, all hazard ratios for non-death outcomes are based on sub-distribution hazards models using Fine-Gray methods to account for the competing risk of death.
Figure 3:
Figure 3:. Risk of In-hospital Outcomes in Patients with PAD & MCS
Adjusted odds ratios for in hospital events amongst patients who received mechanical circulatory support (MCS) with versus without lower extremity peripheral arterial disease (PAD). [CVA/TIA: Cerebrovascular accident/transient ischemic attack]
Figure 4:
Figure 4:. Risk of Out-of-Hospital Outcomes in Patients with PAD & MCS
Cumulative incidence curves and hazard ratios for out-of-hospital outcomes in patients receiving mechanical circulatory support stratified by the presence of lower extremity peripheral artery disease (PAD): a.) Out-of-hospital mortality, b.) Hospitalization for myocardial infarction (MI), c.) Hospitalization for heart failure (HF), and d.) Readmission. For out-of-hospital mortality, cumulative incidence curves estimated using Kaplan Meier methods are displayed. For non-death-related outcomes, cumulative incidence function curves are displayed, which account for the competing risk of death. In addition, all hazard ratios for non-death outcomes are based on sub-distribution hazards models using Fine-Gray methods to account for the competing risk of death.
Figure 4:
Figure 4:. Risk of Out-of-Hospital Outcomes in Patients with PAD & MCS
Cumulative incidence curves and hazard ratios for out-of-hospital outcomes in patients receiving mechanical circulatory support stratified by the presence of lower extremity peripheral artery disease (PAD): a.) Out-of-hospital mortality, b.) Hospitalization for myocardial infarction (MI), c.) Hospitalization for heart failure (HF), and d.) Readmission. For out-of-hospital mortality, cumulative incidence curves estimated using Kaplan Meier methods are displayed. For non-death-related outcomes, cumulative incidence function curves are displayed, which account for the competing risk of death. In addition, all hazard ratios for non-death outcomes are based on sub-distribution hazards models using Fine-Gray methods to account for the competing risk of death.
Figure 4:
Figure 4:. Risk of Out-of-Hospital Outcomes in Patients with PAD & MCS
Cumulative incidence curves and hazard ratios for out-of-hospital outcomes in patients receiving mechanical circulatory support stratified by the presence of lower extremity peripheral artery disease (PAD): a.) Out-of-hospital mortality, b.) Hospitalization for myocardial infarction (MI), c.) Hospitalization for heart failure (HF), and d.) Readmission. For out-of-hospital mortality, cumulative incidence curves estimated using Kaplan Meier methods are displayed. For non-death-related outcomes, cumulative incidence function curves are displayed, which account for the competing risk of death. In addition, all hazard ratios for non-death outcomes are based on sub-distribution hazards models using Fine-Gray methods to account for the competing risk of death.
Figure 4:
Figure 4:. Risk of Out-of-Hospital Outcomes in Patients with PAD & MCS
Cumulative incidence curves and hazard ratios for out-of-hospital outcomes in patients receiving mechanical circulatory support stratified by the presence of lower extremity peripheral artery disease (PAD): a.) Out-of-hospital mortality, b.) Hospitalization for myocardial infarction (MI), c.) Hospitalization for heart failure (HF), and d.) Readmission. For out-of-hospital mortality, cumulative incidence curves estimated using Kaplan Meier methods are displayed. For non-death-related outcomes, cumulative incidence function curves are displayed, which account for the competing risk of death. In addition, all hazard ratios for non-death outcomes are based on sub-distribution hazards models using Fine-Gray methods to account for the competing risk of death.
Central Illustration:
Central Illustration:. PAD Outcomes in Cardiogenic Shock & Myocardial Infarction
In-Hospital and out-of-hospital outcomes in patients with lower extremity peripheral artery disease (PAD) presenting with acute myocardial infarction (MI) and cardiogenic shock.
See this image and copyright information in PMC

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