Elsevier

Cardiovascular Revascularization Medicine

Volume 13, Issue 6, November–December 2012, Pages 328-330
Cardiovascular Revascularization Medicine

The impact of intra-aortic balloon counter-pulsation on in-hospital mortality in patients presenting with anterior ST-elevation myocardial infarction without cardiogenic shock

https://doi.org/10.1016/j.carrev.2012.08.001Get rights and content

Abstract

Objectives

This study aimed to determine whether the elective insertion of an intra-aortic balloon counter pulsation (IABP) device at the time of myocardial revascularization in patients presenting with an acute anterior ST-elevation myocardial infarction (STEMI) without cardiogenic shock has any impact on the in-hospital rate of cardiac mortality.

Background

The role of IABP in patients presenting with an acute MI without cardiogenic shock remains ill defined.

Methods

The present study comprised 605 consecutive patients who underwent primary percutaneous coronary intervention for an anterior STEMI without cardiogenic shock. Patients who received IABP at the time of their coronary revascularization (n = 105) were compared to those who had not (n = 500). Patients with stable angina, unstable angina, non-STEMI, non-anterior STEMI, and cardiogenic shock were excluded.

Results

The two cohorts were well matched for the conventional risk factors for coronary artery disease. Although the left ventricular ejection fraction was significantly lower in the patients who received IABP (0.32 ± 0.11 vs. 0.39 ± 0.12; P < 0.001), the two cohorts were well matched for history of MI, coronary revascularization, and chronic renal impairment. Following propensity scoring, the in-hospital rate of cardiac death was similar between the two cohorts (5.6% vs. 0%; P = .12) as was the rate of vascular complications. Major bleeding was significantly greater in the IABP cohort (10.0% vs. 0%; P = .01) leading to a greater transfusion requirement (14.9% vs. 2.9%; P = .01).

Conclusion

The adjunctive use of an IABP in patients presenting with an acute anterior STEMI without cardiogenic shock may not be associated with an in-hospital mortality benefit.

Introduction

Since the introduction of intra-aortic balloon counter pulsation (IABP) by Kantrowitz et al. for patients with cardiogenic shock, its indications have extended to the provision of circulatory support for patients with de-compensated heart failure, postoperative left ventricular systolic dysfunction, and “high-risk” percutaneous coronary intervention (PCI) [1]. Indeed IABP remains the most commonly used circulatory assist device in the United States with up to 30% of complex PCIs utilizing the device [2].

The use of IABP in patients presenting with acute myocardial infarction (MI) complicated by cardiogenic shock and undergoing PCI has become dogma [3], [4], [5], [6]. Indeed the current American College of Cardiology/American Heart Association (ACC/AHA) guidelines describe IABP therapy as a Class I indication for the treatment of shock complicating acute MI [7]. By contrast, there is currently limited data regarding the role of IABP in patients presenting with acute ST-elevation myocardial infarction (STEMI) without cardiogenic shock who undergo primary PCI [8], [9]. The aim of this study was therefore to determine whether the elective insertion of an IABP device at the time of myocardial revascularization in patients presenting with an acute anterior STEMI without cardiogenic shock has any impact on the in-hospital rate of cardiac mortality.

Section snippets

Methods

This single-center, retrospective study comprised 605 consecutive patients who underwent primary PCI for an anterior STEMI without cardiogenic shock at our institution from 2003 to 2010. Within this cohort, an IABP device was inserted at the time of revascularization in 105 patients. Patients with stable angina, unstable angina, non-STEMI, non-anterior STEMI, and cardiogenic shock were excluded. All patients provided written informed consent. The study complied with the Declaration of Helsinki

Results

Patient baseline characteristics are summarized in Table 1. The two cohorts were well matched for age, sex, and the conventional risk factors for coronary artery disease. In the IABP cohort, the average systolic and diastolic blood pressures prior to IABP were 104 ± 22.3 and 73 ± 16.3, respectively. The average augmented systolic blood pressure was 126 ± 28.3. Although the left ventricular ejection fraction was significantly lower in the IABP patients (0.32 ± 0.11 vs. 0.39 ± 0.12; P < .001), the two

Discussion

The main finding of this single-center, retrospective study is that in patients presenting with an acute anterior STEMI without cardiogenic shock, the use of IABP does not confer any in-hospital survival benefit. Although vascular complication rates were similar between the two cohorts, the rate of major bleeding was greater in the IABP cohort.

The evidence for the use of IABP in patients presenting with an acute MI who are hemodynamically stable is not conclusive in part due to the

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  • Impact of intra-aortic balloon pump on short-term clinical outcomes in ST-elevation myocardial infarction complicated by cardiogenic shock: A “real life” single center experience

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    We included anterior STEMI type as a covariate in the 30-day mortality multivariate regression analysis and no differences were found. In this regard, a recent study evaluated the impact of IABP on in-hospital mortality in patients presenting with acute anterior-STEMI without cardiogenic shock26 and found similar in-hospital rate of cardiac death between the two cohorts (5.6% vs. 0%; p = 0.12). IABP improves myocardial perfusion, reduces myocardial oxygen consumption and furthermore decreases afterload and improves cardiac index,27 which are the principal variables that most be corrected in cardiogenic shock patients.25

  • Overview of the 2012 Food and Drug Administration circulatory system devices panel meeting on the reclassification of external counterpulsation, intra-aortic balloon pump, and non-roller-type cardiopulmonary bypass blood pump devices

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    The CRISP-AMI trial was designed to explore whether the use of IABP in patients with anterior ST-elevation MI without cardiogenic shock would result in reduced infarct size on magnetic resonance imaging but failed to support this hypothesis.20 It was suggested that the advancements in both technical and pharmacological therapy in the treatment of ACS may have confounded the ability to see an adjunctive positive clinical effect of IABP use.21 Conflicting evidence exists regarding the use of IABP for cardiac and noncardiac surgeries.

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