Invasive mechanical ventilation in acute coronary syndromes in the era of percutaneous coronary intervention

Abstract

Percutaneous coronary intervention (PCI) has emerged during the last decades as one of the most important therapeutic tools in patients with acute coronary syndromes (ACS). 1 PCI improves the prognosis of patients with ACS, 2,3 reducing the incidence of ischaemic complications and heart failure, 4 especially in those patients at higher risk, 5-7 thus potentially changing the need for invasive mechanical ventilation (IMV) in this clinical scenario. Little information is available regarding the profile of patients with ACS requiring IMV in the current era. Most of the few published articles regarding this subject come from an era when PCI was not a widespread practice, [8][9][10][11][12] had different methodologies and analyzed quite different populations. [13][14][15] Our objective was to better define the characteristics of ACS patients requiring IMV, the relative frequency of each of the indications for IMV, their in-hospital management Invasive mechanical ventilation in acute coronary syndromes in the era of percutaneous coronary intervention Albert Ariza Solé, Joel Salazar-Mendiguchía, Victòria Lorente-Tordera, José C Sánchez-Salado, José González-Costello, Pedro Moliner-Borja, Joan A Gómez-Hospital, Nicolás Manito-Lorite, Ángel Cequier-Fillat Abstract Background: Percutaneous coronary intervention (PCI) improves prognosis in patients with acute coronary syndromes (ACS) reducing ischaemic complications and the development of heart failure, thus potentially changing invasive mechanical ventilation (IMV) requirements. Little information exists about patients with ACS requiring IMV in the current era. We aimed to analyze IMV requirements and characteristics of ACS patients treated under current recommendations (including a high rate of PCI). Methods: Baseline characteristics, indications for IMV, management and in-hospital and mid-term clinical course were analyzed prospectively in a consecutive series of patients with ACS admitted to a tertiary care hospital. Results: We included 1821 patients, of which 106 (5.8%) required IMV. Mean follow-up was 347 days. PCI was performed in 84% of cases. Patients with IMV had more comorbidities, worse left ventricular function and more unstable hemodynamic parameters on admission. In-hospital mortality in patients requiring IMV was 29%. These patients also had higher mid-term mortality (hazard ratio (HR) 6.58; 95% confidence interval (CI) 4.49−9.64; p 0.001). The most common indication for IMV was cardiopulmonary arrest (CA) (65; 61%), followed by pulmonary oedema (27; 26%) and shock (14; 13.2%). Patients with CA were younger, with better hemodynamic parameters at admission, more favourable coronary anatomy and higher rates of PCI. There were no significant differences in overall mortality between the three groups. The main cause of death in CA patients was persistent vegetative state. Conclusions: Mortality in patients with ACS requiring IMV remained high despite a high rate of PCI. Baseline characteristics, management and clinical course were different according to the rea...

Clinical outcomes of patients undergoing primary percutaneous coronary intervention for acute myocardial infarction requiring the intensive care unit

“…In contrast to previous studies of patients requiring mechanical ventilation or suffering from cardiogenic shock following complicated myocardial infarction, our study reviewed consecutive patients admitted to ICU exclusively via the PPCI pathway [ 8 – 13 , 16 , 17 ]. This included both patients who required mechanical ventilation and those who did not.…”

“…Despite the pervasiveness of PPCI in the management of STEMI and the appropriate use of CCU care, there remains a small proportion of patients that become critically ill and require advanced life support modalities post-PPCI, such as mechanical ventilation or vasoactive therapy that may only be provided within the intensive care unit (ICU). Historically, patients with a complicated myocardial infarction requiring mechanical ventilation have been associated with high rates of morbidity and mortality [ 8 – 13 ].…”

Percutaneous coronary intervention assisted by invasive mechanical ventilation and intra-aortic balloon pump for acute myocardial infarction with cardiogenic shock: Retrospective cohort study and meta-analysis

“…Of the remaining 48 articles, 43 were excluded because of poorly defined IMV use or unreported mortality data. Therefore, five studies were selected for detailed review [ 24 - 28 ], and the study by Kontoyannis et al [ 24 ] was further excluded due to the patient group being small (10 treated with IMV) and the lack of early emergency revascularization therapy by PCI. Finally, four studies in total were included for meta-analysis, and all data from patients treated with IMV were extracted [ 25 - 28 ].…”

“…Therefore, five studies were selected for detailed review [24][25][26][27][28], and the study by Kontoyannis et al [24] was further excluded due to the patient group being small (10 treated with IMV) and the lack of early emergency revascularization therapy by PCI. Finally, four studies in total were included for meta-analysis, and all data from patients treated with IMV were extracted [25][26][27][28]. All four studies reported in-hospital mortality rate, while only one study reported 28-day mortality rate [25].…”

Mechanical ventilation in cardiogenic shock

“…2). Some data suggest that the requirement of mechanical ventilation in patient with acute coronary syndromes, as signs of higher acuity, are burden by higher mortality [39].…”