Differences Between STEMI and NSTEMI Complicated by Cardiogenic Shock

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BACKGROUND: An enhanced understanding is needed of the clinical trajectories seen in contemporary practice among patients with cardiogenic shock (CS) due to different acute myocardial infarction (AMI) types. OBJECTIVES: The objective of the study was to compare clinical characteristics, management strategies, and outcomes among patients with CS due to AMI with and without ST-segment elevation. METHODS: All adults treated for CS due to STEMI or NSTEMI within a multilevel of care health system spanning 11 hospitals from 2016 to 2022 were included. The primary and secondary outcomes were 6-month and in-hospital all-cause mortality. RESULTS: We identified 1,375 patients: 57% ST-segment elevation myocardial infarction with CS (STEMI-CS) and 43% non-STEMI-CS (NSTEMI-CS). STEMI-CS patients had more severe shock with more cardiac arrest and higher initial lactate whereas NSTEMI-CS patients were older with more comorbidities and more severe coronary disease. NSTEMI-CS patients received more coronary artery bypass grafting (33% vs 8%) and lower rates of percutaneous coronary intervention (35% vs 73%) in those undergoing left heart catheterization. Management patterns were consistent across hospital levels. Rates of in-hospital and 6-month mortality (STEMI-CS 37.1% vs NSTEMI-CS 34.0%; P = 0.53) were similar in both groups. On multivariable analysis, revascularization was associated with lower 6-month mortality in both groups, whereas intra-aortic balloon pump or percutaneous ventricular assist device use was associated with lower mortality only in STEMI-CS. Venoarterial extracorporeal membrane oxygenation was associated with increased mortality in both AMI types. CONCLUSIONS: STEMI and NSTEMI patients with CS have distinct clinical profiles and management strategies across all hospital levels. Although they experience similar rates of short and long-term mortality, associations between mechanical circulatory support use and outcomes differ by phenotype. These findings suggest that AMI type should inform management strategies and research design in CS.

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