Keywords
1. Cardiogenic Shock Mortality Malaysia
2. STEMI Treatment in Malaysia
3. Percutaneous Coronary Intervention (PCI) Malaysia
4. Malaysian National Cardiovascular Database
5. Acute Coronary Syndrome Malaysia
A staggering in-hospital mortality rate for patients suffering from cardiogenic shock (CS) after ST-elevation myocardial infarction (STEMI) has been reported in Malaysia, according to a retrospective study published in BMJ Open. The research presents a serious concern for the Malaysian healthcare system and emphasizes the urgent need for improving therapeutic approaches and access to life-saving interventions.
The study, conducted using data from the Malaysian National Cardiovascular Database (NCVD) registry, aimed to explore the incidence, clinical characteristics, and outcomes of STEMI patients with cardiogenic shock in Malaysia. This critical condition presents when the heart suddenly cannot pump enough blood to meet the body’s needs following a severe heart attack.
Over an eight-year period, from 2006 to 2013, a total of 16,517 STEMI patients were identified from 18 hospitals across Malaysia. Researchers found that cardiogenic shock complicated 10.6% of all STEMIs during this time frame. The data highlighted an in-hospital mortality rate of 34.1%, which is over seven times the mortality risk compared with those STEMI patients without CS.
This study serves as the first detailed clinical pattern analysis of this life-threatening complication in the Malaysian setting and reveals critical insights into the mortality risks associated with CS complicating STEMI.
The investigation underscored several factors associated with higher mortality risks, such as age over 65, diabetes mellitus, hypertension, chronic lung disease, and kidney disease. These pre-existing conditions were noted more frequently among those who experienced cardiogenic shock, thus leading to poorer outcomes.
The standard of care for such patients typically involves reperfusion therapy, aiming to restore blood flow to the affected heart muscle. Intravenous thrombolysis remains the primary emergency reperfusion modality in Malaysia. However, the study shows that Percutaneous Coronary Intervention (PCI), an alternative reperfusion technique, conferred a 40% risk reduction in mortality over non-invasive therapy. Despite this significant benefit, only 33.6% of CS complicating STEMI cases underwent PCI.
This substantial gap in the application of PCI points to the need for increased access and availability of invasive therapy for patients. The higher risk-adjusted probability of death and the low application rate of PCI raise questions regarding the healthcare system’s readiness and capacity to manage such severe conditions effectively.
The research team comprised Padmaa Venkatason and associates from the Department of Medicine at the University of Malaya Medical Centre in Kuala Lumpur, alongside collaborators from the Foundation Studies in Science at the University of Malaya. The study was published under the Creative Commons Attribution Non-Commercial (CC BY-NC) license, which allows for reuse with the necessary citations.
To address these findings, the authors suggest that efforts should be made both to improve the utilization rates of invasive therapy like PCI and to establish more streamlined pathways for STEMI patients who develop CS. Studies like this shine a light on the importance of having robust health information systems like the NCVD registry which can provide invaluable data to identify areas of need and inform public health strategies.
The findings from this study are crucial in understanding the Malaysian context for treating acute cardiac events. International research such as the Global Registry of Acute Coronary Events (GRACE) and the SHOCK trial registry contributes to the body of knowledge on managing these conditions but may not fully capture the unique demographic and healthcare delivery circumstances present in Malaysia.
Healthcare professionals and policymakers in Malaysia are urged to take this study’s findings into consideration and work towards improving the quality of care for STEMI patients, with a special focus on those at risk of developing cardiogenic shock. By improving access to and the use of PCI, alongside other advanced cardiac care interventions, the hope is to significantly decrease the mortality rates associated with this highly fatal complication.
DOI: 10.1136/bmjopen-2018-025734
References
1. Venkatason, P., Zubairi, Y. Z., Wan Ahmad, W. A., Hafidz, M. I., Ismail, M. D., Hadi, M. F., & Zuhdi, A. S. M. (2019). In-hospital mortality of cardiogenic shock complicating ST-elevation myocardial infarction in Malaysia: a retrospective analysis of the Malaysian National Cardiovascular Database (NCVD) registry. BMJ open, 9(5), e025734. https://doi.org/10.1136/bmjopen-2018-025734
2. Awad, H. H., Anderson, F. A., Gore, J. M., et al. (2012). Cardiogenic shock complicating acute coronary syndromes: insights from the Global Registry of Acute Coronary Events. Am Heart J, 163, 963–971. https://doi.org/10.1016/j.ahj.2012.03.003
3. Hochman, J. S., Sleeper, L. A., Webb, J. G., et al. (1995). Current spectrum of cardiogenic shock and effect of early revascularization on mortality. Results of an International Registry. Circulation, 91, 873–881.
4. Menon, V., Hochman, J. S. (2002). Management of cardiogenic shock complicating acute myocardial infarction. Heart, 88, 531–537. https://doi.org/10.1136/heart.88.5.531
5. Zuhdi, A. S., Ahmad, W. A., Zaki, R. A., et al. (2016). Acute coronary syndrome in the elderly: the Malaysian National Cardiovascular Disease Database-Acute Coronary Syndrome registry. Singapore Med J, 57, 191–197. https://doi.org/10.11622/smedj.2015145
The unsettling findings in this research provoke a call to action for healthcare providers, government agencies, and stakeholders in the cardiac care arena to establish more responsive and better-resourced cardiac care facilities throughout Malaysia. It is only through a concerted effort to enhance the delivery of care that we can hope to see an improvement in survival rates for those suffering from one of the most severe complications of myocardial infarction—cardiogenic shock.