Regional Variation in the Management and Outcomes of Acute Myocardial Infarction With Cardiogenic Shock in the United States

Abstract

There are few studies evaluating regional disparities in the care of acute myocardial infarction-cardiogenic shock (AMI-CS). Using the National Inpatient Sample from 2000–2016, we identified adults with a primary diagnosis of AMI and concomitant CS admitted to the United States census regions of Northeast, Midwest, South and West. Inter-hospital transfers were excluded. End-points of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), hospitalization costs, length of stay and discharge disposition. Multivariable regression was used to adjust for potential confounding. Of the 402,825 AMI-CS admissions, 16.8%, 22.5%, 39.3% and 21.4% were admitted to the Northeast, Midwest, South and West respectively. Higher rates of ST-elevation AMI-CS were noted in the Midwest and West. Admissions to the Northeast were on average characterized by a higher frequency of Whites, Medicare beneficiaries and lower rates of cardiac arrest. Admissions to the Northeast were less likely to receive coronary angiography, PCI and MCS, despite the highest rates of extracorporeal membrane oxygenation use. Compared to the Northeast, in-hospital mortality was lower in the Midwest (adjusted odds ratio [aOR] 0.96 [95% confidence interval (CI) 0.93–0.98]; p <0.001) and West (aOR 0.96 [95% CI 0.94–0.98]; p =0.001), but higher in the South (aOR 1.04 [95% CI 1.01–1.06]; p =0.002). The Midwest (aOR 1.68 [95% CI 1.62–1.74]; p <0.001), South (aOR 1.86 [95% CI 1.80–1.92]; p <0.001) and West (aOR 1.93 [95% CI 1.86–2.00]; p <0.001) had higher discharges to home. There remain significant regional disparities in the management and outcomes of AMI-CS.