Characteristics of High-Performing Hospitals in Cardiogenic Shock Following Acute Myocardial Infarction

Amit Saha; Shuang Li; James A de Lemos; Ambarish Pandey; Deepak L Bhatt; Gregg C Fonarow; Brahmajee K Nallamothu; Tracy Y Wang; Ann Marie Navar; Eric Peterson; Roland A Matsouaka; Anthony A Bavry; Sandeep R Das; Justin L Grodin; Rohan Khera; Mark H Drazner; Dharam J Kumbhani; NCDR Registry

doi:10.1016/j.amjcard.2024.04.002

Characteristics of High-Performing Hospitals in Cardiogenic Shock Following Acute Myocardial Infarction

Am J Cardiol. 2024 Apr 5:221:19-28. doi: 10.1016/j.amjcard.2024.04.002. Online ahead of print.

Authors

Amit Saha¹, Shuang Li², James A de Lemos¹, Ambarish Pandey¹, Deepak L Bhatt³, Gregg C Fonarow⁴, Brahmajee K Nallamothu⁵, Tracy Y Wang², Ann Marie Navar¹, Eric Peterson¹, Roland A Matsouaka², Anthony A Bavry¹, Sandeep R Das¹, Justin L Grodin¹, Rohan Khera⁶, Mark H Drazner⁷, Dharam J Kumbhani⁸; NCDR Registry

Affiliations

¹ Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
² Duke Clinical Research Institute, Duke University, Durham, North Carolina.
³ Mount Sinai Fuster Heart Hospital, New York, New York.
⁴ Department of Medicine, Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.
⁵ Department of Internal Medicine, Division of Cardiovascular Diseases, University of Michigan, Ann Arbor, Michigan.
⁶ Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Biostatistics, Section of Health Informatics, Yale School of Public Health, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
⁷ Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas. Electronic address: Mark.Drazner@UTSouthwestern.edu.
⁸ Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas. Electronic address: Dharam.Kumbhani@UTSouthwestern.edu.

PMID: 38583700
DOI: 10.1016/j.amjcard.2024.04.002

Abstract

Cardiogenic shock after acute myocardial infarction (AMI-CS) carries significant mortality despite advances in revascularization and mechanical circulatory support. We sought to identify the process-based and structural characteristics of centers with lower mortality in AMI-CS. We analyzed 16,337 AMI-CS cases across 440 centers enrolled in the National Cardiovascular Data Registry's Chest Pain-MI Registry, a retrospective cohort database, between January 1, 2015, and December 31, 2018. Centers were stratified across tertiles of risk-adjusted in-hospital mortality rate (RAMR) for comparison. Risk-adjusted multivariable logistic regression was also performed to identify hospital-level characteristics associated with decreased mortality. The median participant age was 66 (interquartile range 57 to 75) years, and 33.0% (n = 5,390) were women. The median RAMR was 33.4% (interquartile range 26.0% to 40.0%) and ranged from 26.9% to 50.2% across tertiles. Even after risk adjustment, lower-RAMR centers saw patients with fewer co-morbidities. Lower-RAMR centers performed more revascularization (92.8% vs 90.6% vs 85.9%, p <0.001) and demonstrated better adherence to associated process measures. Left ventricular assist device capability (odds ratio [OR] 0.78 [0.67 to 0.92], p = 0.002), more frequent revascularization (OR 0.93 [0.88 to 0.98], p = 0.006), and higher AMI-CS volume (OR 0.95 [0.91 to 0.99], p = 0.009) were associated with lower in-hospital mortality. However, several such characteristics were not more frequently observed at low-RAMR centers, despite potentially reflecting greater institutional experience or resources. This may reflect the heterogeneity of AMI-CS even after risk adjustment. In conclusion, low-RAMR centers do not necessarily exhibit factors associated with decreased mortality in AMI-CS, which may reflect the challenges in performing outcomes research in this complex population.

Keywords: cardiogenic shock; critical care cardiology; myocardial infarction; risk-adjusted mortality rate.