Support or not to support the left ventricle in patients with acute myocardial infarction complicated by cardiogenic shock?
Year: 2013
Type: article
Abstract: To the editor: Cardiogenic shock is one of the devastating complications of acute myocardial infarction. The mortality rate is still unacceptably high though having some treatment options such as complete revascularization, vasoactive drugs and mechanical support devices. Intra-aortic balloon pump (IABP) is the oldest and most frequently used supporting method. In one of the past issues of the journal, Wu et al1 retrospectively analyzed the factors affecting the outcomes of the elderly Chinese patients with cardiogenic shock treated with IABP. This study stimulated us to bring up some controversial issues of IABP support. Some current data in terms of IABP usage should be reviewed more comprehensively beyond knowing the factors affecting the outcomes. As known, IABP reduces afterload of the left ventricle as well as increases coronary blood flow with diastolic augmentation. By 2012, the guidelines classified the use of IABP for patients with cardiogenic shock as class I indication.2 However, further analysis and recent studies raised some questions about the use of the IABP especially during primary percutaneous intervention. In 2011, a systematic review in Cochrane Database showed no 30-day survival benefit of the use of IABP.3 Thiele et al4 reported the 30-day results of IABP -SHOCK II Trial in 2012. The IABP usage for cardiogenic shock did not significantly diminish 30-day mortality. The results of this study at 6 and 12 months were reported by the same group. The similar results were observed in overall study population as well as different subgroups. The independent predictors of mortality at 12 months were age, history of stroke, baseline lactate and creatinine levels, oliguria, pH <7.36 at admission, altered mental status and the presence of left bundle branch block. With these results, the guidelines downgraded the use of IABP from class I to IIA or IIB.2 The controversial results of the IABP usage directed the researchers to investigate the effectiveness of other percutaneous left ventricular assist devices. In the ISAR-SHOCK study published in 2008, 25 patients were randomized to IABP and Impella LS 2.5 device which is one of the percutaneous assist devices. Impella LS 2.5 device showed better hemodynamic results. However, this study was not large enough to make a comment on mortality. In a meta-analysis, the left ventricular assist devices provided better hemodynamic support without any early survival benefit.5 Meanwhile, the effectiveness of left ventricular assist devices including IABP in high-risk percutaneous coronary intervention has been investigated, and mixed results were observed. This subject is clearly another debatable issue. In conclusion, despite being arguable issue, IABP seems to still being used for patients with acute myocardial infarction complicated by cardiogenic shock because of its widespread availability and easiness of implementation. Therefore, it keeps the importance to know the factors affecting mortality in such patients. (Received September 14, 2013) Edited by WANG Mou-yue
Source: Chinese Medical Journal
Authors: Murat Atalay, Mehmet Tezcan, Murat Yalcin, Gokhan Degirmencioglu, Ejder Kardesoglu
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,000
OpenAlex ID: W85245165