The Use of Intra-Aortic Balloon Counterpulsation
Background: Cardiogenic shock complicating acute myocardial infarction (AMI) remains the leading cause of death in patients hospitalized with AMI. Although several studies have demonstrated the importance of establishing and maintaining a patent infarct-related artery, it remains unclear as to whether intra-aortic balloon counterpulsation (IABP) provides incremental benefit to reperfusion therapy. The purpose of this study was to determine whether IABP use is associated with lower in-hospital mortality rates in patients with AMI complicated by cardiogenic shock in a large AMI registry.
Methods: We evaluated patients participating in the National Registry of Myocardial Infarction 2 who had cardiogenic shock at initial examination or in whom cardiogenic shock developed during hospitalization (n = 23,180).
Results: The mean age of patients in the study was 72 years, 54% were men, and the majority were white. The overall mortality rate in all patients who had cardiogenic shock or in whom cardiogenic shock developed was 70%. IABP was used in 7268 (31%) patients. IABP use was associated with a significant reduction in mortality rates in patients who received thrombolytic therapy (67% vs 49%) but was not associated with any benefit in patients treated with primary angioplasty (45% vs 47%). In a multivariate model, the use of IABP in conjunction with thrombolytic therapy decreased the odds of death by 18% (odds ratio, 0.82; 95% confidence interval, 0.72 to 0.93).
Conclusions: Patients with AMI complicated by cardiogenic shock may have substantial benefit from IABP when used in combination with thrombolytic therapy.
Cardiogenic shock complicating acute myocardial infarction (AMI) is associated with high mortality rates and remains the leading cause of death in patients hospitalized with AMI. The largest experience with cardiogenic shock in patients with AMI comes from the GUSTO I trial in which 2972 (7.2%) of 41,021 patients were found to have cardiogenic shock. Whereas mortality rates for such patients had been reported to be as high as 80% in the prethrombolytic era, patients with cardiogenic shock in GUSTO I had a 55% 30-day mortality rate. Whether this reflects a beneficial effect of thrombolysis or the selection of healthier patients for entry into a clinical trial has been debated.
Although several studies have demonstrated the importance of establishing and maintaining a patent infarct-related artery in the setting of AMI complicated by cardiogenic shock, thrombolytic therapy is often unsuccessful in establishing patency of the infarct-related artery in this setting. It has been suggested that the impaired fibrinolytic activity of thrombolytic therapy in patients with cardiogenic shock is in part related to the profound hemodynamic abnormalities that exist in these patients and that this effect could be reversed by norepinephrine. Other studies demonstrated that intra-aortic balloon counterpulsation (IABP), by augmenting perfusion pressure, could also enhance coronary thrombolysis induced by intravenous administration of recombinant tissue plasminogen activator (r-TPA). Preliminary clinical studies support the concept that IABP enhances thrombolysis in the setting of AMI and may prevent reocclusion.
The purpose of this study was to determine whether the use of IABP is associated with a beneficial effect in patients with AMI complicated by cardiogenic shock. To examine this question, we performed a retrospective cohort study with the National Registry of Myocardial Infarction 2 (NRMI 2), a large registry of patients with AMI.
Background: Cardiogenic shock complicating acute myocardial infarction (AMI) remains the leading cause of death in patients hospitalized with AMI. Although several studies have demonstrated the importance of establishing and maintaining a patent infarct-related artery, it remains unclear as to whether intra-aortic balloon counterpulsation (IABP) provides incremental benefit to reperfusion therapy. The purpose of this study was to determine whether IABP use is associated with lower in-hospital mortality rates in patients with AMI complicated by cardiogenic shock in a large AMI registry.
Methods: We evaluated patients participating in the National Registry of Myocardial Infarction 2 who had cardiogenic shock at initial examination or in whom cardiogenic shock developed during hospitalization (n = 23,180).
Results: The mean age of patients in the study was 72 years, 54% were men, and the majority were white. The overall mortality rate in all patients who had cardiogenic shock or in whom cardiogenic shock developed was 70%. IABP was used in 7268 (31%) patients. IABP use was associated with a significant reduction in mortality rates in patients who received thrombolytic therapy (67% vs 49%) but was not associated with any benefit in patients treated with primary angioplasty (45% vs 47%). In a multivariate model, the use of IABP in conjunction with thrombolytic therapy decreased the odds of death by 18% (odds ratio, 0.82; 95% confidence interval, 0.72 to 0.93).
Conclusions: Patients with AMI complicated by cardiogenic shock may have substantial benefit from IABP when used in combination with thrombolytic therapy.
Cardiogenic shock complicating acute myocardial infarction (AMI) is associated with high mortality rates and remains the leading cause of death in patients hospitalized with AMI. The largest experience with cardiogenic shock in patients with AMI comes from the GUSTO I trial in which 2972 (7.2%) of 41,021 patients were found to have cardiogenic shock. Whereas mortality rates for such patients had been reported to be as high as 80% in the prethrombolytic era, patients with cardiogenic shock in GUSTO I had a 55% 30-day mortality rate. Whether this reflects a beneficial effect of thrombolysis or the selection of healthier patients for entry into a clinical trial has been debated.
Although several studies have demonstrated the importance of establishing and maintaining a patent infarct-related artery in the setting of AMI complicated by cardiogenic shock, thrombolytic therapy is often unsuccessful in establishing patency of the infarct-related artery in this setting. It has been suggested that the impaired fibrinolytic activity of thrombolytic therapy in patients with cardiogenic shock is in part related to the profound hemodynamic abnormalities that exist in these patients and that this effect could be reversed by norepinephrine. Other studies demonstrated that intra-aortic balloon counterpulsation (IABP), by augmenting perfusion pressure, could also enhance coronary thrombolysis induced by intravenous administration of recombinant tissue plasminogen activator (r-TPA). Preliminary clinical studies support the concept that IABP enhances thrombolysis in the setting of AMI and may prevent reocclusion.
The purpose of this study was to determine whether the use of IABP is associated with a beneficial effect in patients with AMI complicated by cardiogenic shock. To examine this question, we performed a retrospective cohort study with the National Registry of Myocardial Infarction 2 (NRMI 2), a large registry of patients with AMI.
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