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Cardiogenic Shock and IABP
Clinical problem
A 78 year old man was admitted to A+E following collapse at home, on arrival to
hospital he had a reduced GCS and profound bradycardia with hypotension.
ECG confirmed an inferior MI and complete heart block. Initial management
included airway support, anticholinergics and an isoprenaline infusion all to no
avail. He was therefore transferred to CCU for insertion of a temporary
transvenous pacing wire. Although this achieved “capture” his BP and cardiac
output did not improve, after discussion with his next of kin the decision was
taken to attempt salvage angioplasty with insertion of IABP to treat his refractory
cardiogenic shock.
Management
The angioplasty was successful in revascularising his occluded right coronary
artery however during the procedure he required CPR on several occasions. At
the end of the procedure he was started upon an adrenaline infusion and an
IABP was inserted. Following this his systolic BP dramatically improved and he
began to improve in terms of GCS and urine output. He was admitted to the ICU
for post resuscitation care. Over the next 48 hours he was weaned from the
adrenaline and IABP and avoided and secondary organ damage such as AKI.
He was subsequently discharged from hospital 2 weeks later.
Discussion
The American college of cardiology and the American heart association have
given placement of an IABP for refractory cardiogenic shock complicating acute
MI a class 1 recommendation on the basis of several studies (1,2,3). The most
compelling of these was the TACTICS trial (2) which showed a reduction in 6
month mortality from 80% to 39% (p<0.05) in patients who received IABP. The
benefits of IABP include augmented diastolic pressure and reduced left
ventricular afterload and oxygen demand, together with the fact that in trained
hands it may be inserted “at the bedside”. The complications include arterial
injury and misplacement with potential occlusion of the renal arteries leading to
AKI, which thankfully did not occur in this case.
Lessons learnt
This case highlighted the importance of considering mechanical therapeutic
options in refractory cardiogenic shock and that the IABP represents an
important and effective treatment strategy.
References
1) Antman EM et al. ACC/AHA guidelines for the management of patients
with ST-elevation myocardial infarction. A report of the American college
of cardiology / American heart association task force on practice
guidelines. J Am Coll Cardiol. 2004; 44: E1-E211.
2) Ohman EM et al. Thrombolysis and counterpulsation to improve survival in
myocardial infarction complicated by hypotension and suspected
cardiogenic shock and heart failure: results of the tactics trial. J Thromb
Thrombolysis. 2005; 19: 33-39.
3) Chen et al. Relation between hospital intra-aortic balloon counterpulsation
volume and motality in acute myocardial infarction complicated by
cardiogenic shock. Circulation. 2003; 108: 951-957.
List of Abbreviations
IABP (Intra-aortic balloon pump counterpulsation).