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Efficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shock.

ABSTRACT: BACKGROUND:Guidelines strongly recommend additional intra-aortic balloon pump (IABP) therapy in STEMI patients with cardiogenic shock (CS) treated by primary percutaneous coronary intervention (PCI). However, there is no randomised evidence suggesting survival benefit of IABP treatment in CS. It is suggested that timing of initiation of IABP therapy could be of great importance. Therefore, we compared mortality rates of IABP therapy versus no IABP therapy in the setting of STEMI complicated by CS. In addition, we investigated the effect of initiation of IABP therapy on mortality. METHODS:From a cohort of 292 STEMI patients with CS treated by primary PCI, 199 patients received IABP therapy (IABP group) and 93 patients received no support (no IABP group). The IABP group was divided into two subgroups based on timing of initiation of support, i.e. 'IABP pre PCI' (n?=?59) and 'IABP post PCI' (n?=?140). Outcomes were assessed by propensity stratification and multivariate logistic regression. RESULTS:All-cause 30-day mortality for the IABP versus the no IABP group was 47 % vs. 28 %, respectively, in univariate analysis resulting in an odds ratio (OR) of 1.67 (95%CI, 1.16 to 2.39). However, analyses adjusting outcomes by propensity stratification and logistic regression, respectively, neutralised this OR. In the IABP pre-PCI group vs. the post-PCI group 30-day mortality was 64 % vs. 40 %, resulting in an OR of 1.56 (95 % CI, 1.18 to 2.08). However, after propensity stratification analysis and multivariate logistic regression analysis, there were no significant differences in odds of 30-day mortality. CONCLUSION:In our cohort of patients with STEMI complicated by CS treated with primary PCI we observed a difference in mortality between those treated with IABP and those treated without IABP in favour of the 'no IABP' group. The mortality difference was eliminated after adjustment for differences in case mix by propensity stratification or by logistic regression analysis. Neither did we observe any difference in mortality between patients whose IABP treatment was initiated before or immediately after PCI.

SUBMITTER: Sjauw KD

PROVIDER: S-EPMC3439539 | biostudies-literature | 2012 Oct

REPOSITORIES: biostudies-literature

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Efficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shock.

Sjauw K D KD Engström A E AE Vis M M MM Boom W W Baan J J de Winter R J RJ Tijssen J G P JG Piek J J JJ Henriques J P S JP

Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation 20121001 10

<h4>Background</h4>Guidelines strongly recommend additional intra-aortic balloon pump (IABP) therapy in STEMI patients with cardiogenic shock (CS) treated by primary percutaneous coronary intervention (PCI). However, there is no randomised evidence suggesting survival benefit of IABP treatment in CS. It is suggested that timing of initiation of IABP therapy could be of great importance. Therefore, we compared mortality rates of IABP therapy versus no IABP therapy in the setting of STEMI complica ...[more]

PMID: 22847042

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Project description:AimsThere are limited contemporary data on the use of initial fibrinolysis in ST-segment elevation myocardial infarction cardiogenic shock (STEMI-CS). This study sought to compare the outcomes of STEMI-CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI).MethodsUsing the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI-CS admissions receiving pre-hospital/in-hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI-CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in-hospital mortality, development of non-cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do-not-resuscitate status.ResultsDuring 2009-2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non-White, with lower co-morbidity, and admitted on weekends and to small rural hospitals (all P < 0.001). In the fibrinolysis group, 95.3%, 77.4%, and 15.7% received angiography, PCI, and coronary artery bypass grafting, respectively. The fibrinolysis group had higher rates of haemorrhagic complications (13.5% vs. 9.9%; P < 0.001). The fibrinolysis group had comparable all-cause in-hospital mortality [logistic regression analysis: 28.8% vs. 28.5%; propensity-matched analysis: 30.8% vs. 30.3%; adjusted odds ratio 0.97 (95% confidence interval 0.90-1.05); P = 0.50]. The fibrinolysis group had comparable rates of acute organ failure, hospital length of stay, rates of palliative care referrals, do-not-resuscitate status use, and lesser hospitalization costs.ConclusionsThe use of initial fibrinolysis had comparable in-hospital mortality than those receiving PPCI in STEMI-CS in the contemporary era in this large national observational study.

Project description:Background Clinical outcomes of acute myocardial infarction complicated by cardiogenic shock remain poor with high in-hospital mortality. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been widely used for patients with acute myocardial infarction complicated by cardiogenic shock refractory to conservative therapy, which is likely fatal without mechanical circulatory support. However, whether additional intra-aortic balloon pumping (IABP) use during VA-ECMO support improves clinical outcomes remains controversial. This study sought to investigate prognostic impact of the combined VA-ECMO plus IABP treatment compared with VA-ECMO alone. Methods and Results From the nationwide Japanese administrative case-mix Diagnostic Procedure Combination (DPC), the JROAD (Japanese Registry of All Cardiac and Vascular Diseases)-DPC, we identified 3815 patients with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention and managed with VA-ECMO. Of these, 2964 patients (77.7%) were managed with IABP (VA-ECMO plus IABP), whereas 851 (22.3%) were managed without IABP (VA-ECMO alone). We compared in-hospital, 7-day, and 30-day mortality between the VA-ECMO plus IABP versus the VA-ECMO alone support. Patients managed with VA-ECMO plus IABP demonstrated significantly lower in-hospital, 7-day, and 30-day mortality than those managed with VA-ECMO alone (adjusted odds ratios [95% CI] of 0.47 [95% CI, 0.38-0.59], 0.41 [95% CI, 0.33-0.51], and 0.30 [95% CI, 0.25-0.37], respectively). The findings were consistent in the propensity matching and inverse probability of treatment-weighting models. Conclusions This large-scale, nationwide study demonstrated that the combination of VA-ECMO plus IABP support was associated with significantly lower mortality compared with VA-ECMO support alone in patients presenting with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention.

Dataset Information

Efficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shock.

Publications

Efficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shock.

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