Timing of mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: A systematic review and meta-analysis

Abstract

Background: Acute myocardial infarction (AMI) complicated by cardiogenic shock has a high mortality rate. Mechanical circulatory support (MCS) has been increasingly used; however, the optimal timing for MCS insertion remains uncertain. This study aimed to evaluate outcomes of pre-percutaneous coronary intervention (PCI) vs post-PCI MCS insertion in AMI patients with cardiogenic shock. Methods: A systematic search using 4 databases, including PubMed, Embase, Web of Science, and Cochrane CENTRAL, was conducted from inception to October 25, 2024. Studies comparing outcomes of MCS insertion pre-PCI vs post-PCI in this setting were included. Results: There were 36 studies with a total of 6218 participants were included in this meta-analysis, using a random-effects model. Most of the included studies were non-randomized and retrospective. Early MCS insertion (prior to PCI) was associated with a lower risk of in-hospital mortality compared to late insertion (post-PCI), with an odds ratio (OR) of 0.46 (95%CI 0.36 to 0.57), p < 0.01. Subgroup analysis by MCS type (IABP, Impella, and ECMO) demonstrated that early insertion prior to PCI significantly reduced in-hospital mortality, regardless of the MCS type. Early MCS insertion prior to PCI was also associated with lower 30-day mortality (OR 0.62, (95%CI 0.43 to 0.89), p = 0.01) and 6-month mortality (OR 0.53, (95%CI 0.34 to 0.83), p = 0.01) compared to late insertion. There was no difference in 1-year mortality or in MCS-related complications. Conclusions: Early MCS insertion prior to PCI is potentially associated with reduced in-hospital, 30-day, and 6-month mortality compared to post-PCI insertion in AMI patients with cardiogenic shock.