Summary: Timing of mechanical ventilation and its association with in-hospital outcomes in patients with cardiogenic shock following ST-elevation myocardial infarction: a multicentre observational study
Abstract Summary: This multicentre observational study by Arabi and colleagues investigates the impact of mechanical ventilation (MV) timing on outcomes in 672 patients with STEMI complicated by cardiogenic shock (CS). The study categorizes MV initiation as early (≤15 min), intermediate (30 min), or late (≥60 min) post-shock diagnosis. Key findings reveal that early MV is associated with lower in-hospital mortality (56% vs. 72% in late MV, p=0.001), earlier revascularization, and reduced complications like major bleeding. The mortality risk escalates with delays up to 60 minutes, plateauing thereafter. These results underscore the critical role of timely respiratory support in CS management, though prospective trials are needed to validate causality.
10 Key Points:
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Study Design: Retrospective analysis of 672 STEMI-CS patients from the Gulf-CS registry (13 centers across 6 countries).
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MV Timing Groups:
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Primary Outcome: Late MV independently predicted higher in-hospital mortality (OR 2.14, 95% CI 1.36–3.38).
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Mechanisms: Early MV improves oxygenation, reduces respiratory effort, and facilitates faster revascularization and mechanical circulatory support (MCS) initiation.
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Revascularization: 86% of early MV patients received MV pre-catheterization vs. 16% in late MV (*p*<0.001), correlating with shorter time-to-MCS.
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Complications: Major bleeding was higher in late MV (16.3% vs. 8.5% in early MV, p=0.013).
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Subgroup Analysis: Right coronary artery infarction patients benefited from early MV despite potential RV hemodynamic risks.
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Limitations: Retrospective design, unmeasured confounders (e.g., ventilator settings), and lack of data on pre-MV non-invasive ventilation.
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Clinical Implications: Supports protocolized early MV in STEMI-CS, especially within the first 60 minutes of shock onset.
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Future Directions: Calls for randomized trials to confirm causality and optimize MV timing protocols.
Conclusion:
Arabi et al. demonstrate that early MV initiation (≤15 minutes post-shock) in STEMI-CS patients is linked to significantly lower in-hospital mortality and better clinical outcomes compared to delayed MV. The mortality benefit is time-sensitive, emphasizing the need for prompt respiratory stabilization in CS. While observational limitations exist, these findings advocate for integrating early MV into STEMI-CS algorithms, pending validation through prospective studies.
Watch the following video on “Ventilation and the Heart” by MIC Discussion Forum Dr Haseeb Raza
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