IABP Use Most Risky in ACS Patients Undergoing Urgent PCI

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Intra-aortic balloon pump (IABP) therapy increases bleeding and in-hospital mortality when used during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) or those unexpectedly requiring hemodynamic support as opposed to in elective cases. The results, from an observational study published in the March 2012 issue of JACC: Cardiovascular Interventions, suggest that while IABP use may sometimes be necessary, the benefits and risks should be carefully assessed.

To determine the real-world complication rate of PCI with IABP therapy, researchers led by Antonio Colombo, MD, of San Raffaele Hospital (Milan, Italy), studied the experience at their institution over 12 years. They classified 360 consecutive patients treated between January 1998 and July 2010 into 3 groups:

  • Urgent: 133 patients with ACS in whom IABP therapy was started before PCI
  • Emergent: 56 patients in whom IABP therapy was required to manage hemodynamic acute deterioration during PCI
  • Elective: 171 patients with stable angina in whom IABP therapy was used before PCI

Clear Patterns Seen in Adverse Outcomes

Urgently treated patients experienced far higher rates of in-hospital death and limb ischemia than those in the emergent and elective groups (table 1).

Table 1. In-Hospital Death and Limb Ischemia After PCI with IABP Therapy

 

Urgent
(n = 133)

Emergent
(n = 56)

Elective
(n = 171)

P Value

In-Hospital Death

30.1%

8.9%

0.6%

< 0.0001

Limb Ischemia

4.5%

0.6%

0.025


Overall bleeding, defined according to the Bleeding Academic Research Consortium (BARC) criteria, as well as IABP access site bleeding and transfusion also were more common in the urgent group than the other 2 groups. PCI access site bleeding, meanwhile, was elevated in urgent cases but did not differ significantly (table 2). IABP use accounted for 82% of all access site-related bleeding events.

Table 2. Bleeding After PCI with IABP Therapy

 

Urgent
(n = 133)

Emergent
(n = 56)

Elective
(n = 171)

P Value

BARC Bleeding

30.8%

26.8%

7.0%

< 0.0001

IABP Access Site Bleeding

12.8%

5.4%

4.1%

0.014

PCI Access Site Bleeding

4.5%

1.8%

2.3%

0.461

Transfusion

18.8%

10.7%

2.9%

< 0.0001

Abbreviation: BARC, Bleeding Academic Research Consortium.

Multivariate analyses revealed that IABP treatment duration and renal impairment were the only independent predictors of BARC bleeding.

“Several important aspects can be considered to reduce the rate of bleeding complications in patients requiring IABP support during PCI procedures,” the authors write. “Certainly, the modification of intraprocedural pharmacotherapy by, for example, replacing unfractionated heparin with newer direct thrombin inhibitors, such as bivalirudin, and by reducing the excessive, and often unnecessary, use of [glycoprotein] IIb/IIIa inhibitors would be an important first step.”

Consider Risks When IABP Is Optional

In a telephone interview with TCTMD, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), said these findings should remind interventionalists that IABP use carries risk, even in elective PCI.

“For the other 2 groups, you don’t have a choice. There are complications, but many of those complications are unavoidable,” he said. “The thing to realize is the elective cases also have complications, and you need to be cognizant of that and think about whether it’s worth the risk.”

Dr. Brener added, however, that the bleeding rates seen in this study are about what would be expected and that the 7.0% rate seen in the elective cases is acceptably low.

But the ability to interpret the findings is hindered by the lack of time stratification over the 12 year study period, Dr. Brener commented, because techniques and technologies evolve quickly. “Anything we had 12 years ago does not exist today,” he said, noting that at the beginning of the study there were no convenient alternatives to IABPs in elective cases. “Now we have other options. Today we also have the Impella [Abiomed, Danvers, MA], TandemHeart [CardiacAssist, Pittsburgh, PA], and many other types of left ventricular support devices.”

Another change that has occurred in the past few years, said Dr. Brener, is an overall reduction in the use of hemodynamic support in elective cases simply because interventionalists are realizing it may not be necessary.

Some additional perspective may be provided on March 24 in Chicago, IL, at the American College of Cardiology Annual Scientific Session when the latest findings from the Balloon Pump-Assisted Coronary Intervention Study (BCIS)-1 trial are presented. For this trial, PCI patients with an ejection fraction of less than 30% and extensive myocardium at risk were randomized to elective IABP or ‘no planned’ IABP, in which bailout use was permitted if necessary. To date, analysis of BCIS-1 data has not revealed any significant differences in the primary endpoint (composite of major cardiac and cerebrovascular events at the time of hospital discharge, with a cutoff of 28 days) between the 2 groups.

 


Source:
Davidavicius G, Godino C, Shannon J, et al. Incidence of overall bleeding in patients treated with intra-aortic balloon pump during percutaneous coronary intervention: 12-year Milan experience. J Am Coll Cardiol Intv. 2012;5:350-7.

 

 

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IABP Use Most Risky in ACS Patients Undergoing Urgent PCI

Intra aortic balloon pump (IABP) therapy increases bleeding and in hospital mortality when used during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) or those unexpectedly requiring hemodynamic support as opposed to in elective cases. The results,
Disclosures
  • Drs. Colombo and Brener report no relevant conflicts of interest.

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