Abstract
Background
There are limited data on the outcomes of acute myocardial infarction–cardiogenic shock (AMI-CS) in patients with concomitant cancer.
Methods
A retrospective cohort of adult AMI-CS admissions was identified from the National Inpatient Sample (2000–2017) and stratified by active cancer, historical cancer, and no cancer. Outcomes of interest included in-hospital mortality, use of coronary angiography, use of percutaneous coronary intervention, do-not-resuscitate status, palliative care use, hospitalization costs, and hospital length of stay.
Results
Of the 557,974 AMI-CS admissions during this 18-year period, active and historical cancers were noted in 14,826 (2.6%) and 27,073 (4.8%), respectively. From 2000 to 2017, there was a decline in active cancers (adjusted odds ratio, 0.70 [95% CI, 0.63–0.79]; P < .001) and an increase in historical cancer (adjusted odds ratio, 2.06 [95% CI, 1.89–2.25]; P < .001). Compared with patients with no cancer, patients with active and historical cancer received less-frequent coronary angiography (57%, 67%, and 70%, respectively) and percutaneous coronary intervention (40%, 47%, and 49%%, respectively) and had higher do-not-resuscitate status (13%, 15%, 7%%, respectively) and palliative care use (12%, 10%, 6%%, respectively) (P < .001). Compared with those without cancer, higher in-hospital mortality was found in admissions with active cancer (45.9% vs 37.0%; adjusted odds ratio, 1.29 [95% CI, 1.24–1.34]; P < .001) but not historical cancer (40.1% vs 37.0%; adjusted odds ratio, 1.01 [95% CI, 0.98–1.04]; P = .39). AMI-CS admissions with cancer had a shorter hospitalization duration and lower costs (all P < .001).
Conclusion
Concomitant cancer was associated with less use of guideline-directed procedures. Active, but not historical, cancer was associated with higher mortality in patients with AMI-CS.
Keywords: Cardiogenic shock, myocardial infarction, cancer, outcomes research
Cardiogenic shock (CS) is a life-threatening complication noted in 5% to 10% of all patients with acute myocardial infarction (AMI) and is associated with severe multiorgan dysfunction.1,2 Patients with concomitant acute myocardial infarction–cardiogenic shock (AMI-CS) with prior and active comorbidities, such as renal disease, respiratory failure, and cardiac arrest, have significantly worse prognosis than do those without these comorbidities.3 Although cardiovascular disease, including AMI, continues to be the leading cause of mortality and morbidity in the United States, cancer is a close second.4 In patients with the unfortunate overlap of cancer and heart disease, there appears to be a negative synergistic effect on clinical outcomes.5,6 As a result of advances in oncological treatment, such as targeted therapies with tyrosine kinase inhibitors and immunotherapies, survival rates in patients with cancer have increased significantly.4 However, these patients are at a higher risk for cardiovascular diseases because of the underlying pathophysiology of cancer, the cardiotoxic effects of chemoradiation therapies, and shared atherosclerotic risk factors.7
Cancer is prevalent in approximately 5% to 7% of cases with CS and incurs a mortality rate of 50% in the presence of nonmetastatic cancers, which nearly triples when coexistent with metastatic cancer.1,2 Although increasing adoption of revascularization techniques and preventative interventions has resulted in better survival rates for those with AMI-CS in the current population,8 there are limited data on patients with concomitant cancer.5 Therefore, we sought to assess the impact of concomitant cancers in the management and outcomes of CS complicating AMI in a contemporary US population. We hypothesized that admissions with a cancer diagnosis would have worse outcomes with AMI-CS than outcomes of those without cancer. We also sought to evaluate the differences in the demographics, clinical course, and management strategies of these cohorts to better inform clinical care for these patients.
Patients and Methods
The National/Nationwide Inpatient Sample (NIS) is a part of the Healthcare Quality and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality.9 It is the largest all-payer database of hospital inpatient stays in the United States and contains discharge data from a 20% stratified sample of community hospitals. Information such as patient demographics, primary payer, hospital characteristics, principal diagnosis, up to 29 secondary diagnoses, and procedural diagnoses are available for each discharge. Institutional review board approval was not sought because of the publicly available nature of this deidentified database. The Agency for Healthcare Research and Quality makes these data available to other authors via the HCUP-NIS database.
We used the HCUP-NIS data from January 1, 2000, through December 31, 2017, to identify a cohort of adult admissions (those age >18 years) with AMI in the primary diagnosis field (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] 410.x and International Classification of Diseases, Tenth Edition, Clinical Modification [ICD-10-CM] I21.x-22.x).8,10 A concomitant diagnosis of CS was identified using ICD-9-CM 785.51 and ICD-10-CM R57.0. The administrative codes for CS have high positive predictive value (>90%) and specificity (>95%) but lower sensitivity (>50%).11 Cancer diagnoses were grouped into active and historical cancer. An active cancer diagnosis was identified using the Clinical Classification Software codes provided by the HCUP-NIS, similar to what was done in prior studies.6,12 A historical diagnosis of cancer was identified using the corresponding ICD-9-CM and ICD-10-CM codes (Supplementary Table I).6 The burden of comorbid diseases was identified using the Deyo's modification of the Charlson Comorbidity Index (CCI).13 Demographic characteristics, including age, sex, race, hospital characteristics, acute organ failure, cardiac procedures, and other noncardiac organ support use were identified for all admissions using previously used methodologies from our group (Supplementary Table II).8,10
The primary outcome of interest was in-hospital mortality from AMI-CS among those with active cancer, historical cancer, and without any cancer. The secondary outcomes included use of coronary angiography (CA), percutaneous coronary angiography (PCI), mechanical circulatory support (MCS), and pulmonary artery catheterization (PAC); do-not-resuscitate (DNR) status; palliative care consultation; hospitalization costs; hospital length of stay; and discharge disposition.
Statistical Analysis
In accordance with HCUP-NIS recommendations, survey procedures using discharge weights provided with the HCUP-NIS database were used to generate national estimates. Samples from 2000 to 2011 were reweighted using the trend weights provided by the HCUP-NIS to adjust for the 2012 HCUP-NIS redesign.14 All analyses were conducted, accounting for survey nature (SURVEYMEANS, SURVEYLOGISTIC, and SURVEYFREQ), clustering of admissions within a hospital (HOSP_NIS), weighting (DISCWT), and stratification (NIS_STRATUM) of the HCUP-NIS. One-way analysis of variance and t tests were used to compare categorical and continuous variables, respectively. Temporal trends in the use of CA, PCI, MCS, and PAC were plotted, stratified by the presence and type of cancer. Univariable analysis for trends and outcomes was performed and was presented as odds ratios (ORs) with 95% CIs. Multivariable logistic regression was used to analyze trends over time, and ORs with 95% CIs were calculated for each year compared with the referent year 2000. Multivariable logistic regression analysis incorporating age, sex, race, income status, CCI, primary payer, hospital region, hospital location, hospital teaching status, hospital bed size, acute organ failure, cardiac arrest, CA, PCI, coronary artery bypass grafting, PAC, MCS, invasive mechanical ventilation, and acute hemodialysis was performed to assess temporal trends of in-hospital mortality. For the multivariable modeling, regression analysis with purposeful selection of statistically (liberal threshold of P < .20 in univariate analysis) and clinically relevant variables was conducted.
The inherent restrictions of the HCUP-NIS database related to research design, data interpretation, and data analysis were reviewed and addressed. Pertinent considerations include not assessing individual hospital–level volumes, treating each entry as an “admission” as opposed to an individual patient, restricting the study details to inpatient factors because the HCUP-NIS does not include outpatient data, and limiting administrative codes to those previously validated and used for similar studies. Two-tailed P < .05 was considered statistically significant. All statistical analyses were performed using SPSS v25.0 (IBM Corp).
Results
From more than 11 million AMI admissions between January 1, 2000, and December 31, 2017, we identified a total of 557,974 (5.0% of the total) admissions with a concomitant diagnosis of CS. Active cancer and historical cancer were identified in 14,826 (2.6%) and 27,073 (4.8%) admissions, respectively. The AMI-CS admission rates in those with historical cancers increased over time during this study period, whereas the AMI-CS rates remained relatively stable in those with active cancers (Fig. 1A). Adjusted temporal trends showed a decline in the prevalence of active cancer and a steady increase in historical cancer among AMI-CS admissions (Fig. 1B). Admissions with any type of cancer were on average older, of White race, had a higher CCI, and received care more often at small- or medium-sized hospitals than did admissions without cancer (Table I). Compared with admissions with active cancer, those with a historical cancer diagnosis were on average older, more likely to be female, and had higher rates of hypertension, diabetes, and peripheral vascular disease (Table I).
TABLE I.
Baseline and In-Hospital Characteristics of AMI-CS With and Without Cancer a
| Characteristic (N = 557,974) | No cancer (n = 516,075) | Active cancer (n = 14,826) | Historical cancer (n = 27,073) | P value |
|---|---|---|---|---|
| Age, mean (SD), y | 68.6 (13.0) | 72.5 (11.1) | 75.1 (10.9) | <.001 |
| Sex | ||||
| Female | 198,132 (38.4) | 4,878 (32.9) | 10,995 (40.6) | <.001 |
| Male | 317,943 (61.6) | 9,948 (67.1) | 16,078 (59.4) | |
| Race | ||||
| White | 329,208 (63.8) | 10,503 (70.8) | 20,505 (75.7) | <.001 |
| Black | 32,656 (6.3) | 966 (6.5) | 1,507 (5.6) | |
| Otherb | 154,211 (29.9) | 3,357 (22.6) | 5,061 (18.7) | |
| Primary payer | ||||
| Medicare | 309,650 (60.0) | 10,770 (72.6) | 21,402 (79.1) | <.001 |
| Medicaid | 36,749 (7.1) | 762 (5.1) | 688 (2.5) | |
| Private | 125,640 (24.3) | 2,703 (18.2) | 4,077 (15.1) | |
| Otherc | 44,036 (8.5) | 591 (4.0) | 906 (3.3) | |
| Quartile of median household income for ZIP Code | ||||
| 0–25th | 124,956 (24.8) | 3,266 (22.5) | 5,805 (21.9) | <.001 |
| 26th–50th | 133,882 (26.6) | 3,644 (25.1) | 6,847 (25.8) | |
| 51st–75th | 124,118 (24.7) | 3,709 (25.6) | 6,731 (25.4) | |
| 75th–100th | 120,176 (23.9) | 3,894 (26.8) | 7,129 (26.9) | |
| Charlson Comorbidity Index | ||||
| 0–3 | 152,099 (29.5) | 911 (6.1) | 2,523 (9.3) | <.001 |
| 4–6 | 276,948 (53.7) | 3,595 (24.2) | 8,302 (30.7) | |
| ≥7 | 87,028 (16.9) | 10,320 (69.6) | 16,248 (60.0) | |
| Hypertension | 249,124 (48.3) | 6,990 (47.1) | 15,869 (58.6) | <.001 |
| Congestive heart failure | 267,096 (51.8) | 7,526 (50.8) | 12,832 (47.4) | <.001 |
| Diabetes, uncomplicated | 32,999 (6.4) | 698 (4.7) | 1,646 (6.1) | <.001 |
| Chronic lung disease | 101,470 (19.7) | 3,714 (25.0) | 5,844 (21.6) | <.001 |
| Peripheral vascular disease | 48,514 (9.4) | 1,507 (10.2) | 2,988 (11.0) | <.001 |
| Hospital teaching status and location | ||||
| Rural | 35,649 (6.9) | 1,196 (8.1) | 1,930 (7.1) | <.001 |
| Urban nonteaching | 191,854 (37.2) | 5,401 (36.4) | 9,786 (36.1) | |
| Urban teaching | 288,572 (55.9) | 8,229 (55.5) | 15,357 (56.7) | |
| Hospital bed size | ||||
| Small | 44,611 (8.6) | 1,515 (10.2) | 2,554 (9.4) | <.001 |
| Medium | 120,207 (23.3) | 3,492 (23.6) | 6,599 (24.4) | |
| Large | 351,257 (68.1) | 9,819 (66.2) | 17,920 (66.2) | |
| Hospital region | ||||
| Northeast | 93,210 (18.1) | 2,676 (18.0) | 4,935 (18.2) | <.001 |
| Midwest | 116,365 (22.5) | 3,496 (23.6) | 6,966 (25.7) | |
| South | 201,393 (39.0) | 5,384 (36.3) | 9,245 (34.1) | |
| West | 105,108 (20.4) | 3,270 (22.1) | 5,928 (21.9) | |
| AMI type | ||||
| ST elevation | 343,475 (66.6) | 8,891 (60.6) | 16,364 (60.4) | <.001 |
| Non–ST elevation | 172,601 (33.4) | 5,845 (39.4) | 10,709 (39.6) | |
| Cardiac arrest | 149,721 (29.0) | 3,532 (23.8) | 6,724 (24.8) | <.001 |
| Early CA | 220,053 (42.6) | 5,091 (34.3) | 11,686 (43.2) | <.001 |
| CA | 358,389 (69.4) | 8,505 (57.4) | 18,068 (66.7) | <.001 |
| PCI | 253,404 (49.1) | 5,981 (40.3) | 12,805 (47.3) | <.001 |
| CABG | 91,622 (17.8) | 1,381 (9.3) | 3,541 (13.1) | <.001 |
| Acute organ failure | ||||
| Respiratory | 243,083 (47.1) | 6,801 (45.9) | 11,891 (43.9) | <.001 |
| Hepatic | 48,104 (9.3) | 1,221 (8.2) | 2,119 (7.8) | <.001 |
| Renal | 195,403 (37.9) | 5,856 (39.5) | 10,559 (39.0) | <.001 |
| Hematologic | 63,157 (12.2) | 2,086 (14.1) | 2,999 (11.1) | <.001 |
| Neurologic | 78,668 (15.2) | 1,826 (12.3) | 3,383 (12.5) | <.001 |
| MCS | 235,215 (45.6) | 4,801 (32.4) | 10,398 (38.4) | <.001 |
| PAC | 37,814 (7.3) | 870 (5.9) | 1,626 (6.0) | <.001 |
| IMV | 222,205 (43.1) | 6,287 (42.4) | 10,661 (39.4) | <.001 |
| Prolonged IMV | 81,789 (15.8) | 2,021 (13.6) | 2,799 (10.3) | <.001 |
| Noninvasive mechanical ventilation | 17,989 (3.5) | 720 (4.9) | 1,361 (5.0) | <.001 |
| Acute hemodialysis | 14,468 (2.8) | 371 (2.5) | 559 (2.1) | <.001 |
AMI, acute myocardial infarction; CA, coronary angiography; CABG, coronary artery bypass grafting; CS, cardiogenic shock; IMV, invasive mechanical ventilation; MCS, mechanical circulatory support; PAC, pulmonary artery catheterization; PCI, percutaneous coronary intervention
Data are presented as No. (%), unless otherwise specified. P < .05 was considered statistically significant.
Hispanic, Asian or Pacific Islander, Native American, other.
Self-pay, no charge, other.
Fig. 1.
Trends in the prevalence of cancer and in-hospital mortality of acute myocardial infarction with cardiogenic shock (AMI-CS). A) Unadjusted temporal trends of the proportion of AMI-CS admissions with active cancer and historical cancer stratified by type of AMI (P < .001 for trend over time).
Fig. 1.
B) Adjusted odds ratio for the prevalence of active and historical cancer in STEMI and NSTEMI admissions (with 2000 as the referent), adjusted for age; sex; race; Charlson Comorbidity Index; primary payer; income status; and hospital region, location, teaching status, and bed size (P < .001 for trend over time). C) Unadjusted IHM in AMI-CS admissions stratified by the presence and type of cancer (P < .001 for trend over time).
Fig. 1.
D) Adjusted odds ratio for IHM by year (with 2000 as the referent) in AMI-CS admissions stratified by presence and type of cancer and adjusted for age; sex; race; income status; Charlson Comorbidity Index; primary payer; hospital region, location, teaching status, and bed size; acute organ failure; cardiac arrest; coronary angiography; percutaneous coronary intervention; coronary artery bypass grafting; pulmonary artery catheterization; mechanical circulatory support; invasive mechanical ventilation; and acute hemodialysis (P <. 001 for trend over time). P < .05 was considered statistically significant.
AMI, acute myocardial infarction; CS, cardiogenic shock; IHM, in-hospital mortality; NSTEMI, non–ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction
Admissions without cancer had higher rates of ST-segment elevation myocardial infarction (STEMI)-CS presentation, concomitant cardiac arrest, acute non-cardiac organ failure, and noncardiac organ support (Table I). Those with active and historical cancer had lower rates of CA, PCI, coronary artery bypass grafting, MCS, and PAC use than did those without a concomitant cancer diagnosis (Table I). The lower rates of CA, PCI, and MCS use were prevalent throughout the study period and seen in both STEMI and non–ST-segment-elevation myocardial infarction (NSTEMI) admissions (Fig. 2A, Fig. 2B, and Fig. 2C, respectively). A decline in the use of PAC was seen across all subgroups over the 18-year period (Fig. 2D).
Fig. 2.
Temporal trends of the proportion of AMI-CS admissions receiving A) coronary angiography, B) PCI, C) MCS, and D) PAC stratified by presence and type of cancer, and type of AMI (P < .001 for trend over time for all). P < .05 was considered statistically significant. AMI, acute myocardial infarction; CS, cardiogenic shock; MCS, mechanical circulatory support; NSTEMI, non–ST-segment-elevation myocardial infarction; PAC, pulmonary artery catheterization; PCI, percutaneous coronary intervention; STEMI, ST-segment-elevation myocardial infarction
Fig. 2.
Temporal trends of the proportion of AMI-CS admissions receiving A) coronary angiography, B) PCI, C) MCS, and D) PAC stratified by presence and type of cancer, and type of AMI (P < .001 for trend over time for all). P < .05 was considered statistically significant. AMI, acute myocardial infarction; CS, cardiogenic shock; MCS, mechanical circulatory support; NSTEMI, non–ST-segment elevation myocardial infarction; PAC, pulmonary artery catheterization; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction
In both unadjusted and adjusted analyses, admissions with an active cancer diagnosis had higher in-hospital mortality (45.9% vs 37.0%, respectively; unadjusted OR, 1.44 [95% CI, 1.40–1.49]; P < .001; adjusted OR, 1.29 [95% CI, 1.24–1.34]; P < .001) mortality than did those without cancer (Supplementary Table III). Admissions with historical cancer had higher unadjusted mortality than (40.1% vs 37.0%, respectively; OR, 1.14 [95% CI, 1.11–1.17]; P < .001) but similar adjusted inhospital mortality (OR, 1.01 [95% CI, 0.98–1.04]; P = .39) to those without cancer. Temporal trends showed a decline in in-hospital mortality in both admissions with and without cancer among STEMI and NSTEMI admissions across the 18-year period (Fig. 1C and Fig. 1D). DNR status and palliative care consultation were used more often among those with an active cancer diagnosis (Table II). Compared with those without cancer, admissions with active and historical cancer diagnoses had shorter lengths of in-hospital stays and lower hospitalization costs (Table II). However, they were less likely to be discharged home and had more frequent discharges to skilled nursing facilities and home with home health care than did those without cancer (Table II).
TABLE II.
Clinical Outcomes of AMI-CS With and Without Cancer
| Characteristic | No cancer (n = 516,075) | Active cancer (n = 14,826) | Historical cancer (n = 27,073) | P valuea |
|---|---|---|---|---|
| In-hospital mortality, No. (%) | 190,758 (37.0) | 6,789 (45.9) | 10,840 (40.1) | <.001 |
| Length of stay, median (IQR), d | 7 (3–13) | 6 (3–11) | 5 (2–10) | <.001 |
| Do-not-resuscitate status, No. (%) | 36,293 (7.0) | 1,930 (13.0) | 3,987 (14.7) | <.001 |
| Palliative care consultation, No. (%) | 30,632 (5.9) | 1,723 (11.6) | 2,806 (10.4) | <.001 |
| Hospitalization costs (×1,000 USD), median (IQR) | 91.9 (43.5–178.3) | 72.3 (31.0–144.2) | 79.8 (36.3–154.9) | <.001 |
| Discharge disposition | ||||
| Home | 136,631 (42.1) | 2,737 (34.3) | 6,161 (38.1) | <.001 |
| Transfer | 37,116 (11.4) | 841 (10.5) | 1,812 (11.2) | |
| Skilled nursing facility | 95,129 (29.3) | 2,680 (33.6) | 5,081 (31.4) | |
| Home with HHC | 53,740 (16.6) | 1,685 (21.1) | 3,078 (19.0) | |
| Against medical advice | 1,588 (0.5) | 35 (0.4) | 41 (0.3) |
AMI , acute myocardial infarction; CS, cardiogenic shock; HHC, home health care; IQR, interquartile range
P < .05 was considered statistically significant.
Discussion
In the largest study assessing management and outcomes in patients with AMI-CS and a concomitant cancer diagnosis, we noted that active and historical cancer complicated 2.6% and 4.8% of all AMI-CS admissions, respectively. Admissions with active cancer less frequently underwent CA, PCI, MCS, and PAC. They had higher rates of in-hospital mortality, greater frequency of DNR status, palliative care consultation, and shorter hospital stay. Those with historical cancer diagnosis had mortality outcomes similar to those of patients without cancer.
The incidence and temporal trends of CS complicating AMI have increased in the past 2 decades,15,16 but there are limited studies evaluating these trends in patients with cancer. Using the HCUP-NIS database, Bharadwaj and coworkers demonstrated an increase in AMI prevalence in those with active cancer (from 2.5% to 3.0% over a period of 10 years).6 The increase is even larger in those with historical cancer (from 4.8% to 7.7%), which is similar to the findings in our study.6 Recent statistics by American Cancer Society reveal a 29% decline in mortality rates of all cancers since 1991, and an increase in the estimated 5-year survival rate of 72%, owing to advancements in cancer therapies.4 Many survivors live a cancer-free life but acquire cardiovascular risk factors from smoking exposure, physical inactivity, obesity, and secondary cardiotoxic side effects from chemoradiation therapies.17 Cancer also triggers hypercoagulability and a proinflammatory status, which leads to a higher risk of incurring coronary events, including AMI and CS,18 the possibility of which is highest at the time of a cancer diagnosis and at the initiation of cancer therapies.19 The risk remains elevated for months to years after treatment completion.19 All these mechanisms may explain the temporal increase in the prevalence of historical cancers in the AMI-CS cohort. Furthermore, the increase in longevity in the US population, in combination with the lifestyle hazards, is contributing to the prevalence of the combination of heart disease and cancer, which carries a poor overall prognosis.
Among the subtypes of AMI-CS, STEMI-CS is more prevalent in the general population,20 and this finding reflects those of other cohorts with cancer. However, when AMI without CS is comorbid with cancer, NSTEMI is more prevalent.21 In our results from the cancer cohort, although we observed STEMI-CS to be the dominant subtype, it occurred in a lower proportion than the NSTEMI-CS subtype. Munoz and colleagues and Giza and colleagues both independently showed the etiology for more than 10% of NSTEMI cases in cancer to be Takotsubo cardiomyopathy.22,23 NSTEMI from Takotsubo cardiomyopathy occurred more commonly in solid malignancies than in hematologic malignancies and was triggered mostly by physical and secondarily by emotional stress. Those with Takotsubo cardiomyopathy in cancer were also at a 20% elevated risk of complication by CS.23 Apart from NSTEMI from Takotsubo cardiomyopathy, the NSTEMI-CS in our cancer cohorts could also be attributed to a higher incidence of myocardial injury resulting in type 2 AMI than in the no-cancer cohort; however, by restricting this analysis to those with a primary diagnosis of NSTEMI, we sought to limit the inclusion of type 2 AMI admissions.22
The AMI-CS cancer cohort has notably significant treatment disparities with lower use of life-saving invasive technologies, particularly in those with active cancer.24,25 In cohorts with AMI only (ie, without CS) and cancer, Itzhaki Ben Zadok and colleagues observed that a lower percentage of patients with cancer were referred to CA and PCI than were those in the no-cancer population, respectively.26 However, the study by Bharadwaj and coworkers revealed a significantly lower number of active cancer cohorts receiving CA, PCI, or coronary artery bypass grafting than with the historical cancer or no-cancer group; this is in line with our previous observations in AMI-CS cancer cohorts.6 Cancer cohorts have a 24% likelihood of not receiving PCI and 36% lower likelihood of receiving any invasive management.25 The treatment options are subject to additional variability depending on the type and metastatic status of cancer.6 Velders and colleagues revealed that the cancer cohorts have a longer door-to-balloon times, receive PCI less frequently, and receive mostly bare-metal stents (even though previous studies have reported a higher rate of in-stent thrombosis in cancer) compared with the general population receiving drug-eluting stents.27 Although most of the registries and clinical trials excluded patients with cancer, the management of AMI-CS in this cohort should be the same as for the general population, that is, medical optimization and early revascularization.28 Observational studies have revealed improved overall survival of this cohort after receiving guideline-directed procedures and have shown a reasonable tolerability to dual-antiplatelet therapies with an acceptably low risk of bleeding complications.29 But invasive therapies are undeniably higher risk in this cohort and incur a 3-fold higher chance of mortality, specifically in newly diagnosed active cancers.30 The Society of Coronary Angiography and Interventions expert consensus statement recommends special considerations for revascularization in cancer cohorts, including a multidisciplinary approach to assessing safety and weighing risk/benefit ratio when considering emergent revascularization.31 A study by Styczkiewicz et al21 compared outcomes between cancer that were managed conservatively vs invasively and concluded that those treated conservatively incurred high rates of short-term and 1-year mortality risk. Unfortunately, despite the existing guideline recommendations, the use of CA, PCI, MCS, and PAC has been low in the cancer cohorts in our study. On the other hand, in our research, the general population, despite incurring higher in-hospital complications with multiorgan failure and cardiac arrest, received more aggressive treatments. These disparities can be potentially explained by the perceived pessimism toward the presence of the cancer diagnosis; lack of adequate prognostic information during an acute emergency; hematological disturbances, such as anemia or thrombocytopenia, that might limit the use of antiplatelet therapies; and concerns about adverse complications.7 This represents a unique opportunity to incorporate cardio-oncology teams into acute cardiovascular care to promote careful, patient-centric decision-making.
The past 2 decades have witnessed a decline in the temporal trends of AMI-CS–related mortality rates.16 Although the trends in cancer-related mortality are also declining, Bharadwaj et al6 evaluated in-hospital mortality in AMI cancer cohorts and found active cancers to have twice the mortality rate of that for patients with historical or no cancer, which is in line with our observations. On the contrary, a different cohort by Itzhaki Ben Zadok et al26 looked at AMI in cancer and revealed no difference in short-term outcomes regarding in-hospital complications, mortality, or major cardiac adverse events, but it did predict a higher 1-year mortality risk (hazard ratio, 2.52; P < .001).Comparing the demographics of patients with cancer and patients with no cancer from this and previous studies, the cancer cohort has a far higher prevalence of previous cardiac events, such as AMI, multiorgan dysfunction with peripheral vascular diseases, renal disease, cerebrovascular disease, and anemia, which in itself makes this cohort a sicker population.30 AMIs in cancer that are notably high risk are those with a high Global Registry of Acute Coronary Events risk score, worse Killip class,26 and an elevated risk of complications with the major adverse cardiovascular or cerebrovascular event, stroke rates, and bleeding.6 Theys also receive less-aggressive management of AMI-CS by way of increased palliative care consultation and DNR status. This potentially alludes to the higher use of treatment-limiting decisions than in those without concomitant cancer, particularly in patients with STEMI-CS with cancer because they are the sickest of all.10 This explain the survival rates in this cohort being lower than those in the contemporary population.
Despite the HCUP-NIS database's attempts to mitigate potential errors by using internal and external quality control measures, this study has several limitations. The use of previously validated administrative codes for AMI and CS reduces inherent errors.11 The lack of granular data, such as echocardiographic data, angiographic variables, and hemodynamic parameters, precludes an assessment of disease severity. Information such as the timing of multiorgan failure and CS relative to AMI presentation are also not available in HCUP-NIS. In addition, the NIS does not provide information on duration of cancer, current treatment status, cause of in-hospital death, laboratory parameters, and other relevant clinical data that affect management strategies and outcomes in these patients. It is possible that the observed results could be from residual confounding despite attempts at controlling for confounders through a multivariate analysis. Our data are only reflective of in-hospital outcomes and cannot be extrapolated to the long-term outcomes of these admissions. Even considering these limitations, this study provides insights on the effects of cancer in the AMI-CS population.
In conclusion, admissions with AMI-CS and an active cancer diagnosis had higher in-hospital mortality, whereas those with historical cancer diagnosis had mortality similar to those of admissions without cancer. A concomitant cancer diagnosis appears to influence the management of these patients who are critically ill, as evidenced by the lower rates of cardiac procedure use in our study. Additional qualitative and quantitative research evaluating the factors affecting the care and outcomes of AMI-CS patients with cancer is needed.
Funding Statement
Funding/Support: None
Footnotes
Author Contribution: Drs Patlolla and Bhat contributed equally to this manuscript as co-first authors.
Conflict of Interest Disclosures: None
Disclaimer: All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Meeting Presentation: Bhat AG, Patlolla SH, Vallabhajosyula S. Outcomes of acute myocardial infarction-cardiogenic shock with coexisting cancer. Presented at: American College of Cardiology Scientific Sessions; May 15, 2021; Atlanta, GA. Poster 3290.
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