Available online 21 February 2024

Author links open overlay panel, , , , , , , AbstractBackground

Conventionally, in the pre-percutaneous intervention era, free wall rupture is reported to be a major concern for using steroids in myocardial infarction (MI) patients. Therefore, the aim of this study was to evaluate the safety of the use of steroids in critically ill post-MI patients in terms of hospital course and short-term (up to 180-day) mortality.

Methods

We included patients admitted to CCU diagnosed with MI, undergone revascularization, critically ill, and requiring mechanical ventilator (MV) support. The hospital course and short-term (up to 180-day) mortality were independently compared between steroid and non-steroid cohorts and propensity-matched non-steroid cohorts.

Results

A total of 312 patients were included, out of which steroids were used in 93(29.8%) patients during their management. On periodic bedside echocardiography, no free wall rupture was documented in the steroid or non-steroid cohort. When compared steroids with a propensity-matched non-steroid cohort, MV duration >24 hours was 66.7% vs. 59.1%; p=0.288, major bleeding was 6.5% vs. 3.2%; p=0.305, need for renal replacement therapy was 9.7% vs. 8.6%; p=0.799, in-hospital mortality was 35.5% vs. 23.7%; p=0.077, and 180-day mortality was 48.4% vs. 41.9%; p=0.377, respectively. The hazard ratio was 1.22 [95% CI: 0.80 to 1.88] compared to the propensity-matched non-steroid cohort. The ejection fraction (%) was found to be the independent predictor of 180-day mortality with an adjusted odds ratio of 0.92 [95% CI: 0.86 to 0.98].

Conclusions

In conclusion, using steroids is safe in post-MI patients with no significant increase in short-term mortality risk.

Section snippetsBACKGROUND

Acute Myocardial Infarction (AMI) triggers a complex inflammatory response influenced by various factors, and these roles evolve through both the pro-inflammatory and anti-inflammatory reparative phases that follow AMI. Patients with AMI accompanied by Cardiogenic Shock (AMI-CS) are particularly vulnerable to developing an inflammatory phenotype that leads to pathological vasodilation.1 Systemic inflammation is commonly observed in AMI-CS patients, which can be triggered by the AMI itself, a

Study setting

This is a sub-group analysis of the data collected for a prospective observational cohort study conducted at the critical care unit (CCU) of the NICVD (National Institute of Cardiovascular Diseases), Karachi, Pakistan. The data was collected for the utility of admission frailty score in the prognostication of post-myocardial infarction patients requiring advanced life support. The study duration was six months, from August 2021 to January 2022. The study was approved by the ethical review

RESULTS

A total of 312 patients were included, out of which steroids were used in 93 (29.8%) patients during their management. The use of steroid was found to associate with older age (63.05 ± 11.56 vs. 59.16 ± 11.31; p=0.006), IWMI (14% vs. 5%), longer ischemic time (12 [10 - 48] vs. 10 [6 - 18]; p<0.001), sub-optimal TIMI flow (22.6% vs. 12.8%), prolonged (>24 hours) ventilator time (66.7% vs. 41.1%; p<0.001), biventricular failure (47.3% vs. 30.6%; p=0.005), elevated LVEDP (28.2 ± 9.75 vs. 25.56 ±

DISCUSSION

Using steroids in managing patients with acute myocardial infarction (AMI) is controversial, with conflicting evidence regarding its efficacy and safety. Our study investigated the association of steroid use with clinical variables and outcomes in patients with STEMI complicated by cardiogenic shock. Our study showed that steroid use was more common in patients with several adverse variables, including older age, longer ischemic time, sub-optimal TIMI flow post-reperfusion, prolonged ventilator

LIMITATIONS

The present study has some limitations that should be considered. First, the study was conducted in a single center with a small sample size with low event rate, especially for the ventricular rupture, hence, study on a larger cohort would be helpful. Therefore, the results may not be generalizable to other populations. Second, the study did not evaluate long-term outcomes beyond 180 days. Third, the study did not assess the specific dose or duration of steroid used, which may have influenced

STRENGTHS

Our study evaluated multiple clinical variables, comprehensively assessing the association between steroid use and AMI outcomes. We also used propensity matching to account for potential confounding factors between the steroid and non-steroid cohorts, which increases the validity of the finding. This study may be one of the first few investigating the safety of steroids in patients who have been re-perfused with percutaneous angioplasties following MI. It also identified important predictors of

CONCLUSION

The use of steroids in AMI patients is not recommended by current guidelines, and their routine use as a therapeutic anti-inflammatory agent for myocardial injury should be avoided, however when warranted by other clinical indications, low to moderate doses of steroids are not associated with worse outcomes and may be safe to use. Larger clinical randomized trials are still needed to disprove the earlier notion regarding steroid safety.

Uncited Floats

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Ethics approval and consent to participate

This study was approved by the ethical review committee of the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan (ERC/74/2021). Verbal informed consent was obtained from all the patients regarding their participation in the study and publication of data while maintaining confidentiality and anonymity. Due to the observational nature of the study, the ERC waived the written consent, and verbal consent was approved by the ERC.

Source of funding

None to declare.

Authors' contributions

MM, MIA, JA, contributed to the concept and design of study, MM, MIA, LT, JA, MK, contributed to the analysis and interpretation of data, MM, MIA, MU, MH, MSA, and LT, collected data and drafted the manuscript, and JA, MIA, and MK, critically analysed for content. All author approved the final draft to the manuscript.

Conflicts of interest

All authors have no conflict of interest to disclose.

Acknowledgments

The authors wish to acknowledge the support of the staff members of the Clinical Research Department of the National Institute of Cardiovascular Diseases (NICVD) Karachi, Pakistan.

References (23)P Théroux et al.Prognostic significance of blood markers of inflammation in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty and effects of pexelizumab, a C5 inhibitor: a substudy of the COMMA trial

Eur Heart J

(2005)

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© 2024 Published by Elsevier Inc. on behalf of Southern Society for Clinical Investigation.