Have We Given Up on Intra‐aortic Balloon Counterpulsation in Post–Myocardial Infarction Cardiogenic Shock?

Abstract The recently published Intra‐aortic Balloon Pump in Cardiogenic Shock II (IABP‐SHOCK II) trial concluded that intra‐aortic counterpulsation (IACP) does not reduce 30‐day mortality in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) for whom early revascularization strategy was planned. The study resulted in downgrading IACP in post‐AMI CS patients by certain professional organizations like the European Society of Cardiology. Although this is the largest and most important CS study of this decade, it suffers from considerable shortcomings: (1) time intervals from chest‐pain onset or AMI recognition to revascularization, enrollment, and IACP initiation are not disclosed; (2) 86.6% of the treatment arm initiated IACP only post–percutaneous coronary intervention (PCI), and 4.3 % did not receive IACP at all; (3) 17.4% of the control arm crossed over to IACP or other mechanical support, mostly due to protocol violations; (4) there is no adjudication of the mortality events; (5) follow‐up is limited to 30 days; and (5) both methodology (especially IACP device size) and quality of IACP are not evaluated and documented. Because the study assessed mostly the efficacy and safety of IACP initiated post‐PCI, the study conclusions should not be extrapolated to IACP pre‐PCI or during PCI in CS. Moreover, IACP had a favorable effect on the mortality of younger patients. Intra‐aortic counterpulsation should remain th...
Source: Clinical Cardiology - Category: Cardiology Authors: Tags: Commentary Source Type: research

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This is written by Brooks Walsh.https://twitter.com/BrooksWalshA 30 year-old woman was brought to the ED with chest pain.It had started just after nursing her newborn, about an hour prior, and she described it as a severe non-pleuritic “pressure” radiating to the back.She had given birth a week ago, and she had similar chest pain during her labor. She attributed the chest pain to anxiety and stress, saying " I'm just an anxious person. "A CXR and a CTA for PE were normal.The ECGsAn initial ECG was obtained as the pain was rapidly resolving:Minimal upsloping ST Elevation in III, with a steeply biphasic...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Conclusions. We report the use of IABP in patients with acute chest pain admitted for angiography. Long-term survival is acceptable and discriminating factors were no revascularisation, out-of-hospital cardiac arrest and age. IABP was safe and feasible and the complication rate was low. PMID: 31476881 [PubMed - as supplied by publisher]
Source: Scandinavian Cardiovascular Journal - Category: Cardiology Tags: Scand Cardiovasc J Source Type: research
Fluoropyrimidines are chemotherapeutic agents that confer great benefit to many patients with solid tumors, but their use is often limited by cardiotoxicity. The incidence and precise mechanisms of cardiotoxicity remain uncertain. Clinical presentations of fluoropyrimidine toxicity are varied and include chest pain, myocardial infarction, acute cardiomyopathy, arrhythmia, cardiogenic shock, and sudden cardiac death. Proposed mechanisms include coronary vasospasm, coronary endothelial dysfunction, direct myocardial toxicity, myocarditis, and Takotsubo cardiomyopathy. Therapeutic and prophylactic interventions primarily targ...
Source: Cardiology Clinics - Category: Cardiology Authors: Source Type: research
Post by Smith and MeyersSam Ghali (https://twitter.com/EM_RESUS) just asked me (Smith):" Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR? "Smith and Meyers answer:First, LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded.But if they do present:The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion, though it might be due to subtotal LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia. ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
CONCLUSION: In patients with cardiogenic shock after delivery, early transthoracic echocardiography is a non-invasive tool that can rapidly narrow the differential diagnosis. PMID: 31324480 [PubMed - as supplied by publisher]
Source: Journal of Obstetrics and Gynaecology Canada : JOGC - Category: OBGYN Tags: J Obstet Gynaecol Can Source Type: research
CONCLUSION: Coronary artery disease should be systematically evoked in the presence of ventricular dysfunction in patients with systemic lupus, including when they are young and in the absence of chest pain. Nephrotic syndrome should be identified as a risk factor for arterial thrombosis. PMID: 30981562 [PubMed - as supplied by publisher]
Source: Revue de Medecine Interne - Category: Internal Medicine Tags: Rev Med Interne Source Type: research
Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.-----------------------------------------------------------Comment by KEN GRAUER, MD (2/5/2019):-----------------------------------------------------------Exce...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Abstract A 44-year-old male with ongoing chest pain and left ventricular ejection fraction 400 s: multiple argatroban bolus doses were required, along with accelerated up-titration of infusion dosing. Despite maintaining an ACT>484 s, clot formation was observed in the cardiotomy reservoir prior to separation. Subsequently, the patient developed severe disseminated intravascular coagulopathy, with both intra-cardiac and intravascular thrombi, requiring massive transfusion and continuous cell saving due to severe hemorrhage post cardiopulmonary bypass (CPB). The patient received a total of 105 units of plasma, 7...
Source: Perfusion - Category: Cardiovascular & Thoracic Surgery Authors: Tags: Perfusion Source Type: research
A 60-something presented with hypotension, bradycardia, chest pain and back pain.She had a h/o aortic aneurysm, aortic insufficiency, peripheral vascular disease, and hypertension.  She had a mechanical aortic valve.  She was on anti-hypertensives including atenolol, and on coumadin, with an INR of 2.3. She was ill appearing.  BP was 70/49, pulse 60.A bedside echo showed good ejection fraction and normal right ventricle and no pericardial fluid. Here is the initial ECG:What do you think?This ECG actually looks like a left main occlusion (which rarely presents to the ED alive):  ST Elevation in...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Conclusion: If there is multiple ST segment elevation in presentation electrocardiography, clinicians should be aware of possible simultaneous coronary occlusions.
Source: Medical Principles and Practice - Category: Internal Medicine Source Type: research
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