Peripheral Artery Disease in Acute Myocardial Infarction With Cardiogenic Shock

Comorbid peripheral artery disease (PAD) in patients with acute myocardial infarction and cardiogenic shock was associated with death and lower extremity amputation or revascularization according to research findings published in the Journal of the American College of Cardiology.

Lower extremity PAD is a comorbidity in almost half of patients with coronary artery disease (CAD). When CAD leads to acute myocardial infarction (AMI), cardiogenic shock is the leading cause of death. Research is lacking for the association between PAD and the aftermath of AMI and cardiogenic shock.

Researchers sought to examine the outcomes of comorbid PAD among patients with AMI and cardiogenic shock, and compare use of mechanical circulatory support (MCS) between patients with and without PAD. Death was the primary outcome. Lower extremity revascularization, amputation, stroke, and bleeding were secondary outcomes.

To accomplish this, they conducted a retrospective data analysis of 71,690 Medicare beneficiaries with AMI and cardiogenic shock, hospitalized in the US from October 2015 to June 2018. Of these patients, 4259 (5.9%; aged 77.8±7.9 years; 58.7% men; 84.3% White) had PAD. In-hospital mortality was higher for patients with PAD (56.3% with vs 46.6% without; adjusted odds ratio [aOR], 1.50; 95% CI, 1.40-1.59), as was out-of-hospital mortality (67.9% with PAD vs 40.7% without; adjusted hazard ratio [aHR], 1.78; 95% CI, 1.67-1.90). Amputation also was higher among patients with PAD (1.6% with vs 0.2% without; aOR: 7.0; 95% CI: 5.26-9.37). Bleeding and lower extremity revascularization were also slightly higher among patients with PAD.

Patients with PAD were less likely have received MCS (21.5% vs 38.6% without PAD; P <.001) and were at increased risk for amputation, lower extremity revascularization and mortality.

Study limitations included that there were unmeasured confounders and the older study population restricts generalizability. There was also selection bias related to identifying patients with PAD and possible underdiagnosis of PAD.

Researchers noted the importance of MCS to treat cardiogenic shock, and the less frequent use of MCS in patients with AMI, cardiogenic shock, and comorbid PAD. They also noted the poorer outcomes when MCS was used in this population.

“Comorbid established PAD is a significant risk factor for adverse events among patients who present with [cardiogenic shock] and AMI, and is associated with worse limb outcomes as well as poorer short-term and long-term survival compared with those without PAD,” the researchers wrote. “Ultimately, the optimal management strategy for patients with PAD presenting with CS and AMI may be multidisciplinary, with early involvement from vascular specialists, until prospective data can inform optimal revascularization and mechanical circulatory support decision-making.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

Reference

Mihatov N, Mosarla RC, Kirtane AJ, et al. Outcomes associated with peripheral artery disease in myocardial infarction with cardiogenic shock. J Am Coll Cardiol. Published online April 5, 2022. doi:10.1016/j.jacc.2022.01.037