The risks and benefits of three treatment strategies were examined in 64 consecutive patients with acute myocardial infarction and cardiogenic onset Thirteen patients received thrombolytic therapy (group 1) 29 patients received intra-aortic balloon cross-examine counterpulsation support (group 2).

The risks and benefits of three treatment strategies were examined in 64 consecutive patients with acute myocardial infarction and cardiogenic onset Thirteen patients received thrombolytic therapy (group 1) 29 patients received intra-aortic balloon cross-examine counterpulsation support (group 2), and patients were treated with combined thrombolytic therapy and intra-aortic balloon cross-question counterpulsation support (group 3). The clusters were similar in regard to age, sex medical history, hemodynamic data, and compass of coronary artery disease. Survival was improved in patient treated with combined thrombolytic therapy and intra-aortic balloon cross-examine counterpulsation support (group 1, 23 percent; clump 2, 28 percent; and assign places to 3, 68 percent; p=0.0049). Seven percent of the patients who remained at the community hospital survived v 69 percent who were transferred to a tertiary care center (p [les than] 0001) and 17 percent survived who were treated medically v 71 percent who received revascularization (p [les than] 0001) These findings give an inkling of that patients who present to a community hospital in cardiogenic collision can have their conditions stabilized, and they can then be transferred to a tertiary care hospital for revascularization and have the same consequence as patients who initially at hand to tertiary care hospitals.

Five to ten percent of patients who current to a community hospital with acute myocardial infarction will expand cardiogenic shock.[1,2] Despite new advances in thrombolytic therapy for the treatment of acute myocardial infarction, 65 to 90 percent of these patients will not survive.[3,4] latter studies have indicated that acute percutaneous coronary angioplasty may remodel mortality in this patient group[56] Unfortunately, greatest in number community hospitals do not have angioplasty capabilities. Alternative strategies for the treatment of acute myocardial infarction associated with cardiogenic assault in community hospitals must, therefore, be explored.

This consideration was undertaken to examine the risks and benefits of a treatment strategy that combines thrombolytic therapy with intra-aortic balloon interrogate counterpulsation support and early transfer to a tertiary care hospital for revascularization in patients who ready to the community hospital with acute myocardial infarction and cardiogenic shock

METHODS

The studious mood sample consisted of all patients admitted to a community teaching hospital with a diagnosis of acute myocardial infraction and cardiogenic assault between January 1985 and January 1991 (n=64) The medical records were retrospectively reviewed to determine the issue of treatment strategies in this high-risk patient population. The diagnosis of acute myocardial infarction was based forward the following: (1) characteristic chest pain; (2) greater than 2 mm ST portion elevation in more than pair leads on a standard 12-lead electrocardiogram; (3) elevation of total creatine phosphokinase enzyme level; and (4) elevation of creatine phosphokinase-MB of the same height There were no standard protocols for the treatment of cardiogenic conflict Treatment strategies were determined by means of each cardiologist. Thrombolytic therapy or intra-aortic balloon cross-question counterpulsation support intervention was preferr during the initial meditation period. Combining intra-aortic balloon cross-examine counterpulsation with thrombolytic therapy and early transfer to a tertiary care hospital for difficulty coronary artery reperfusion with coronary angioplasty or coronary bypass surgery evolv during the application of mind period.

Intra-aortic balloon interrogate counterpulsation was used only after persistent cardiogenic stroke was demonstrated. We defined cardiogenic concussion as a systolic blood press of less than or equal to 80 mm Hg after completing fluid resuscitation. All patients required inotropic line pressure support and had peripheral signs of soft cardiac output. All patients had united or more of the following findings: decreased urine output of les than 30 ml/h self-possessed extremities, or changes in mental status with associated hypotension. In the patients who received hemodynamic monitoring, the cardiac index was les than 20 L/min/[m.sup.2], and the pulmonary capillary wedge constraining force was greater than or equal to 18 mm Hg

For all patients who required an intra-aortic balloon cross-examine the method of percutaneous insertion was utilized. The majority of the intra-aortic balloon cross-examines were inserted under fluoroscopic guidance. An 18-gauge Argon needle followed from a 0.035-mm guidewire, a 105-French sheath, and a 95-French balloon (Percor, Percor STAT DL Datascope Corporation, Paramus, NJ) via the femoral artery were used in all patients. The technique of entering sole the anterior wall of the femoral artery was used.

The choice of thrombolytic agent was made at the discretion of the cardiologist. Thrombolytic therapy consisted of either tissue plasminogen activator (alteplase [Activase], Genentech Inc, toward the south San Francisco, Calif) in a dosage of 100 mg administered throughout 3 h, or streptokinase (Kabikinase, KabiVitrum AB, Stockholm, Sweden) in a dosage of 15 million units administered athwart 1 h as described in the respective manufacturer's literature.[7,8]

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