Treatment of Acute Myocardial Infarction and Cardiogenic Shock: Outcomes of the RECOVER III Postapproval Study by Society of Cardiovascular Angiography and Interventions Shock Stage

Abstract

Background: The Society for Cardiovascular Angiography and Interventions proposed a staging system (A-E) to predict prognosis in cardiogenic shock. Herein, we report clinical outcomes of the RECOVER III study for the first time, according to Society for Cardiovascular Angiography and Interventions shock classification.

Methods and results: The RECOVER III study is an observational, prospective, multicenter, single-arm, postapproval study of patients with acute myocardial infarction with cardiogenic shock undergoing percutaneous coronary intervention with Impella support. Patients enrolled in the RECOVER III study were assigned a baseline Society for Cardiovascular Angiography and Interventions shock stage. Staging was then repeated within 24 hours after initiation of Impella. Kaplan-Meier survival curve analyses were conducted to assess survival across Society for Cardiovascular Angiography and Interventions shock stages at both time points. At baseline assessment, 16.5%, 11.4%, and 72.2% were classified as stage C, D, and E, respectively. At ≤24-hour assessment, 26.4%, 33.2%, and 40.0% were classified as stage C, D, and E, respectively. Thirty-day survival among patients with stage C, D, and E shock at baseline was 59.7%, 56.5%, and 42.9%, respectively (P=0.003). Survival among patients with stage C, D, and E shock at ≤24 hours was 65.7%, 52.1%, and 29.5%, respectively (P<0.001). After multivariable analysis of impact of shock stage classifications at baseline and ≤24 hours, only stage E classification at ≤24 hours was a significant predictor of mortality (odds ratio, 4.8; P<0.001).

Conclusions: In a real-world cohort of patients with acute myocardial infarction with cardiogenic shock undergoing percutaneous coronary intervention with Impella support, only stage E classification at ≤24 hours was significantly predictive of mortality, suggesting that response to therapy may be more important than clinical severity of shock at presentation.

Keywords: Society for Cardiovascular Angiography and Interventions shock class; acute myocardial infarction with cardiogenic shock; cardiogenic shock; mechanical circulatory support; percutaneous coronary intervention.

Figure 1. Change in Society of Cardiovascular Angiography and Interventions (SCAI) shock stage from pre‐Impella to 24 hours post‐Impella initiation.

Of 413 patients with SCAI shock stage classification performed before Impella implant, 411 had available data to perform repeated SCAI shock stage classification within 24 hours of Impella initiation.

Figure 2. Survival through 30 days.

Kaplan‐Meier survival curve estimates in stage C, D, and E Society of Cardiovascular Angiography and Interventions (SCAI) shock stage subgroups per baseline shock classification (N=68, 47, and 298, respectively) (A), and stage C, D, and E subgroups per classification performed within 24 hours of Impella initiation (N=110, 139, and 166, respectively) (B). A Cox model estimated hazard ratios (HRs) for the effect of stage D and E shock stages (with SCAI shock stage C as the reference variable) on mortality through 30 days.

Figure 3. Receiver operating characteristic curves of Society of Cardiovascular Angiography and Interventions (SCAI) shock classifications (at baseline and ≤24 hours) for mortality through 30 days.

SCAI classification performed within 24 hours of Impella placement showed more predictive utility for early mortality than baseline SCAI shock classification, with a model considering both classifications showing incrementally higher utility. AUC indicates area under curve.

Figure 4. National Cardiogenic Shock Initiative (NCSI) report card.

Use of NCSI best practices in the RECOVER III study population. Maintain cardiac power output >0.6 W was not included, as a limited number of patients had available data to assess this. PA indicates pulmonary artery; PCI, percutaneous coronary intervention; and TIMI, Thrombosis in Myocardial Infarction.