Safety of intraaortic balloon counterpulsation in patients with acute myocardial infarction receiving streptokinase intravenously

Thrombolysis plus aortic counterpulsation: improved survival in patients who present to community hospitals with cardiogenic shock

OBJECTIVES

We sought to explore the potential benefit of combining intraaortic balloon counterpulsation (IABP) with thrombolysis for acute myocardial infarction (MI) complicated by cardiogenic shock.

BACKGROUND

In community hospitals, this condition is usually managed with thrombolysis alone.

METHODS

We reviewed the charts of 335 patients from two community hospitals who presented with acute MI and had cardiogenic shock between 1985 and 1995.

RESULTS

Of 46 patients who underwent thrombolysis within 12 h of acute infarction with confirmed cardiogenic shock, 27 underwent IABP and 19 did not. Age, systolic blood pressure with shock, pulmonary artery catheter use, pulmonary capillary wedge pressure and the incidence of diabetes mellitus and anterior MI did not differ between groups. Patients treated with IABP were somewhat more likely to have prior MI and had a significantly greater cardiac index (2.0 vs. 1.5 liters/min per m2, p = 0.04). Although no deaths occurred within 2 h of presentation, patients not treated with IABP tended to die earlier (6.8 +/- 5 vs. 23.8 +/- 19 h, p = 0.13). Patients treated with IABP had a significantly higher rate of community hospital survival (93% vs. 37%, p = 0.0002), and more of them were transferred for revascularization (85% vs. 37%). Of 30 patients transferred for revascularization, 27 underwent angioplasty or bypass surgery; hospital survival was 74%. Patients treated with IABP also had a significantly higher overall hospital and 1-year survival rate (67% vs. 32%, p = 0.019).

CONCLUSIONS

Survival may be enhanced and transfer for revascularization facilitated when community hospitals use both thrombolysis and IABP to treat patients with acute MI complicated by cardiogenic shock.

The use of intraaortic balloon counterpulsation in acute myocardial infarction and high risk coronary angioplasty

Patients with complex coronary arterial stenoses, decreased ejection fraction, or acute myocardial infarction are at increased risk during percutaneous coronary interventions. Intraaortic balloon counterpulsation (IABP) can provide benefit in such cases by several mechanisms. Myocardial perfusion is improved and left ventricular afterload is reduced by balloon counterpulsation. Patients with cardiogenic shock clearly benefit from balloon counterpulsation until revascularization can be performed. Recent studies have documented the utility of balloon counterpulsation in patients undergoing angioplasty as treatment for an acute myocardial infarction. Balloon counterpulsation is also an effective means to reduce ischemia and provide hemodynamic support during complex percutaneous coronary interventions. This review will summarize the benefits, indications, and complications of balloon counterpulsation during acute myocardial infarction and high-risk coronary angioplasty.

Treatment strategies for acute myocardial infarction complicated by cardiogenic shock in a community hospital

The risk and benefits of three treatment strategies were examined in 64 consecutive patients with acute myocardial infarction and cardiogenic shock. Thirteen patients received thrombolytic therapy (group 1), 29 patients received intra-aortic balloon pump counterpulsation support (group 2), and 22 patients were treated with combined thrombolytic therapy and intra-aortic balloon pump counterpulsation support (group 3). The groups were similar in regard to age, sex, medical history, hemodynamic data, and extent of coronary artery disease. Survival was improved in patients treated with combined thrombolytic therapy and intra-aortic balloon pump counterpulsation support (group 1, 23 percent; group 2, 28 percent; and group 3, 68 percent; p = 0.0049). Seven percent of the patients who remained at the community hospital survived vs 69 percent who were transferred to a tertiary care center (p < 0.001), and 17 percent survived who were treated medically vs 71 percent who received revascularization (p < 0.001). These findings suggest that patients who present to a community hospital in cardiogenic shock can have their conditions stabilized, and they can then be transferred to a tertiary care hospital for revascularization and have the same outcome as patients who initially present to tertiary care hospitals.

Is use of the intraaortic balloon pump in octogenarians justified?

Increasing numbers of octogenarians are seen in the operating room or critical care unit with circumstances for which intraaortic balloon pump (IABP) assistance is appropriate, but it has been suggested that the complication rate for IABP use in octogenarians is excessive. From 1980 to 1990, 25 octogenarians needed an IABP in our institution, as an adjunct to operation in 20 patients (1 had repair of a ventricular rupture and 19 underwent coronary grafting); 5 patients did not have operation. The indications for IABP use were unstable angina, 12 (48%); cardiogenic shock, 10 (40%); and difficulty weaning off cardiopulmonary bypass, 3 (12%)--these 3 were the only ones who had insertion through a femoral cut-down. No serious insertion difficulties were noticed with the percutaneous route in the other 22 patients. Without operation, 4 of 5 patients died in the hospital (80%), and the 5th died 2 years 8 months after discharge. After operation, there were two hospital deaths (10%) and two late deaths, neither from cardiac causes. A fatal outcome occurred in 6 of 9 patients with cardiogenic shock. Intraaortic balloon pump-related complications were rare, minor, and unrelated to IABP assistance duration, which ranged from 24 to 146 hours (mean, 49.9 hours). No long-term vascular complications resulted. Hospital stay averaged 22.2 days. At follow-up from 9 to 81 months (mean, 51.8 months), of the 16 survivors, 12 (75%) were in New York Heart Association class I/II and 2 each were in classes III and IV.(ABSTRACT TRUNCATED AT 250 WORDS)

Complications of intraaortic balloon counterpulsation insertion in patients receiving thrombolytic therapy for acute myocardial infarction

This study retrospectively examines 38 patients who presented with acute myocardial infarction requiring intraaortic balloon pump counterpulsation. Two groups of patients were identified. Group I consisted of patients with acute myocardial infarction treated with intraaortic balloon pump without thrombolytic therapy. Group II consisted of patients treated with intraaortic balloon pump after receiving intravenous thrombolytic therapy. These groups were compared and contrasted with regard to previously identified complications associated with intraaortic balloon pump counterpulsation including loss of limb and mortality. The need for surgery, embolectomy, and drainage of hematoma were also evaluated. The need for surgery in group II (11%) and in both groups combined (7%) is lower than is generally reported in literature (range 11.6% to 34%). In addition, no patients experienced a loss of limb and no patients in the study had severe life-threatening iatrogenic morbidity or mortality. While mortality was not an end point in this study, it was noted that there was an increased survival rate in group II patients with 61% surviving until the time of hospital discharge. Also, eight out of 14 patients in group II who underwent intraaortic balloon pump counterpulsation for cardiogenic shock survived until the time of discharge. This represents a 57% survival rate for patients presenting with cardiogenic shock. We conclude that intraaortic balloon pumps can be inserted safely following thrombolytic therapy in a community hospital.