Bleeding and Cardiogenic Shock: An “Unholy Alliance”?

Courtesy of Dr. Carlos Fava.

Mortality in acute myocardial infarction (MI) with cardiogenic shock (CS) has been reduced over the past two decades. This has been possible thanks to early angioplasty, greater operator (and overall medical team) experience, new antiplatelet therapies, and ventricular assist devices, which have also been somewhat relevant in this setting.

However, in MI without CS, bleeding is a well-known significant mortality factor. In CS, its mortality risk is 20% or more, and the use of ventricular assist devices increase it between 40% and 70%.

Its real incidence, the factors that cause it, and the severity of its prognosis have not been entirely studied yet.

A subanalysis of the CULPRIT-SHOCK trial included 684 patients. Among them, 147 had bleeding events (21.5%).

There were no differences among groups: the mean age was 70 years old, there was a higher proportion of men, most patients had an ST-segment elevation MI, and over half of them received CPR.

Read also: ESC 2018 | CULPRIT-SHOCK: 1-Year Results Continue to Support Treatment of the Culprit Artery Only.

A high percentage of bleeding events occurred within the first two weeks (57%); a third of them were classified as BARC 3, and 5.4% were fatal.

Patients with bleeding events received mechanical ventilation and treatment with vasoactive substances over a longer period of time. There was a significant association with sepsis, peripheral ischemic complications, new atrial fibrillation, and ventricular fibrillation.

At 30 days, the presence of bleeding events was associated with higher mortality (hazard ratio [HR]: 2.11; 95% confidence interval [CI]: 1.63 to 2.75; p < 0.0001), especially in cases of bleeding higher than 3b.

Read also: The CULPRIT-SHOCK Study Is Finally Published in NEJM and It Is Bound to Change Guidelines.

Extracorporeal membrane oxygenation (ECMO) and Impella were the main risk factors for bleeding.

Conclusion

Risk of bleeding in acute MI with cardiogenic shock is associated with increased mortality.

Courtesy of Dr. Carlos Fava.

Original Title: Frequency and Impact of Bleeding on Outcome in Patients With Cardiogenic Shock.

Reference: Anne Freund, et al. J Am Coll Cardiol Intv 2020;13:1182–93.

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