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Objectives: To identify whether the prognostic implications of Vasoactive Inotropic Score according to use of mechanical circulatory support differ in the treatment of acute myocardial infarction complicated by cardiogenic shock.Design: A multicenter retrospective and prospective observational cohort study.Setting/patient: The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy registry includes 1,247 patients with cardiogenic shock from 12 centers in Korea. A total of 836 patients with acute myocardial infarction complicated by cardiogenic shock were finally selected, and the study population was stratified by quartiles of Vasoactive Inotropic Score (< 10, 10-30, 30-90, and > 90) for the present study.Interventions: None.Measurements and Main Results: Primary endpoint was in-hospital mortality and secondary endpoint was follow-up mortality. Among the study population, 326 patients (39.0%) received medical treatment alone, 218 (26.1%) received intra-aortic balloon pump, and 292 (34.9%) received extracorporeal membrane oxygenation. In-hospital mortality occurred in 305 patients (36.5%) and was significantly higher in patients with higher Vasoactive Inotropic Score (15.6%, 20.8%, 40.2%, and 67.3%, for < 10, 10-30, 30-90, and > 90; p < 0.001). Vasoactive Inotropic Score showed better ability to predict in-hospital mortality in acute myocardial infarction patients with cardiogenic shock who received medical treatment alone (area under the curve: 0.797; 95% CI, 0.728-0.865) than in those who received intra-aortic balloon pump (area under the curve, 0.704; 95% CI, 0.625-0.783) or extracorporeal membrane oxygenation (area under the curve, 0.644; 95% CI, 0.580-0.709). The best cutoff value of Vasoactive Inotropic Score for the prediction of in-hospital mortality also differed according to the use of mechanical circulatory support (16.5, 40.1, and 84.0 for medical treatment alone, intra-aortic balloon pump, and extracorporeal membrane oxygenation, respectively). There was a significant interaction between Vasoactive Inotropic Score as a continuous value and the use of mechanical circulatory support including intra-aortic balloon pump (interaction-p = 0.006) and extracorporeal membrane oxygenation (interaction-p < 0.001) for all-cause mortality during follow-up.Conclusions: High Vasoactive Inotropic Score was associated with significantly higher in-hospital and follow-up mortality in patients with acute myocardial infarction complicated by cardiogenic shock. The predictive value of Vasoactive Inotropic Score for mortality was significantly higher in acute myocardial infarction patients with cardiogenic shock treated by medical treatment alone than in those treated by mechanical circulatory support such as intra-aortic balloon pump or extracorporeal membrane oxygenation. [ABSTRACT FROM AUTHOR]

Introduction: Mortality is very high in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) or cardiac arrest despite intensive use of percutaneous coronary intervention (PCI). Although current guidelines still recommend rapid revascularization in these high-risk patients, several studies showed the benefit of extracorporeal membrane oxygenation (ECMO)-assisted PCI. Hypothesis: ECMO support before revascularization might be beneficial in patients with AMI complicated by profound CS after resuscitated cardiac arrest. Methods: Among 116,374 patients experiencing out-of-hospital cardiac arrest in all emergency medical service of South Korea between 2013 and 2016, a total of 147 resuscitated patients with AMI complicated by profound CS who were treated with both PCI and ECMO were enrolled. Exclusion criteria were as follows: non-cardiac arrest, duration of cardiopulmonary resuscitation < 20 minutes, patients without restoration of spontaneous circulation, patients treated with thrombolysis, patients who did not receive PCI, patients did not receive ECMO treatment, and cases of failed PCI. Enrolled patients were divided into two groups according to timing of ECMO; pre-PCI ECMO group (n = 82) vs. post-PCI ECMO group (n = 65). We compared 30-day mortality between two groups. Results: Age and proportion of male gender were similar between 2 groups. The rate of bystander CPR (29.3% vs. 29.2%, p = 0.996) and shockable rhythm at emergency room (26.8% vs. 26.2%, p = 0.927) were also comparable in 2 groups. Although total duration of CPR was similar between 2 groups (57.4±27.6 vs. 52.0±28.8 minutes, p = 0.313), door to revascularization time was significantly longer in pre-PCI ECMO group than post-PCI ECMO group (123.7±57.6 vs. 105.5±39.1 minutes, p = 0.030). At 30-days, overall mortality was 80.3% (118 patients) in study population, and it was significantly lowered in pre-PCI ECMO group (72.0% vs. 90.8%, p = 0.004). In multivariate Cox-regression analysis, pre-PCI ECMO reduced 30-day mortality compared to post-PCI ECMO (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.47-0.98, p = 0.041). Bystander CPR , shockable rhythm at emergency room and successful therapeutic hypothermia were also associated with reduced 30-day mortality. Conclusions: ECMO treatment before PCI was associated with reduced 30-day mortality compared to ECMO after revascularization in patients with AMI complicated by profound CS after resuscitated cardiac arrest. [ABSTRACT FROM AUTHOR]