Temporal Trends in Acute Myocardial Infarction with Concomitant Cardiogenic Shock and Chronic Total Occlusions: Insights from The National Inpatient Sample (2008-2022)

RAHUL Singh; SHREE LAYA Vemula; SUDHISH Gogula; SUDHAKAR Prabhu; ALEKSANDRE Toreli; SUDHANVA Hegde; VIKRAM Sharma

doi:10.1016/j.chest.2025.07.290

PURPOSE: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains a significant cause of in-hospital mortality, particularly when complicated by a coronary chronic total occlusion (CTO). Using the National Inpatient Sample, this study aimed to examine the national trends, and outcomes of CTOs in AMI-CS from 2008–2022. METHODS: We performed a retrospective analysis of the National Inpatient Sample from January 1, 2008, to December 31, 2022. Admissions with a primary diagnosis of acute myocardial infarction (AMI) and secondary diagnoses of chronic total occlusion (CTO) and cardiogenic shock (CS) were identified via validated ICD-9/ICD-10 codes in patients undergoing diagnostic angiography. Elective admissions and those transferred to other hospitals were excluded from this analysis. Outcomes included in-hospital mortality, mechanical circulatory support (MCS) utilization (intra-aortic balloon pump [IABP], left ventricular assist device [LVAD], extracorporeal membrane oxygenation [ECMO]), mechanical ventilation, and length of stay (LOS). Multivariable logistic regression with survey weighting, adjusted for patient- and hospital-level variables, produced yearly estimates via marginal means. RESULTS: 491,129 admissions with a primary diagnosis of AMI involved CTO, and 41,296 (8.4%) had concurrent CS. The cohort was predominantly White (76.7%), male (69.6%), and had a primary diagnosis of STEMI (72%). Mortality was 32.2% overall, remaining unchanged over the study period (P = 0.87). MCS was utilized in 57.6% of admissions (IABP in 51.6%, LVAD in 7.8%, ECMO in 0.95%), yet its overall rate decreased significantly (64.1% to 45.1%; P < 0.01), mainly due to reduced IABP adoption (year-on-year odds ratio [OR], 0.89; 95% confidence interval [CI], 0.88–0.91) despite increasing LVAD use (OR, 1.26; 95% CI, 1.23–1.30). Mechanical ventilation use declined significantly from 36.9% to 26.7% (P < 0.01), while in-hospital CABG following PCI decreased from 4.7% to 1.6% (P < 0.01), and LOS decreased from 9.3 to 6.9 days (P < 0.01). CONCLUSIONS: In this nationwide study of AMI-CS admissions with CTO, overall MCS utilization declined over time—primarily due to decreased IABP use—while LVAD utilization rose. Despite improvements in the need for CABG after PCI and reduced length of stay, there was no significant change in mortality over time. CLINICAL IMPLICATIONS: These findings reinforce the need for further investigation into risk stratification, optimization of mechanical circulatory support, and targeted revascularization strategies to improve outcomes in AMI-CS complicated by CTO.

Temporal Trends in Acute Myocardial Infarction with Concomitant Cardiogenic Shock and Chronic Total Occlusions: Insights from The National Inpatient Sample (2008-2022)

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