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Mechanical Circulatory Support in Patients Undergoing PCI
Study Questions:
What is the overall utilization and temporal change in the patterns of utilization of standard (i.e., intra-aortic balloon pump [IABP]) and newer mechanical support therapies across the United States for patients undergoing percutaneous coronary intervention (PCI) in the setting of cardiogenic shock or high-risk PCI?
Methods:
The investigators identified 76,474 patients who underwent PCI in the setting of cardiogenic shock at one of 1,429 National Cardiovascular Data Registry (NCDR) CathPCI participating hospitals from 2009 to 2013. Temporal trends and hospital-level variation in the use of IABP and other mechanical circulatory support (O-MCS) were evaluated. The authors assessed temporal trends in the use of IABP and O-MCS by plotting the quarterly use of these devices. They then applied an interrupted time series analysis (i.e., segmented regression) to assess trends in IABP and O-MCS use before and after publication of the IABP-SHOCK II trial.
Results:
No MCS was used in 41,286 (54%) patients, 29,730 (39%) received IABP only, 2,711 (3.5%) received O-MCS only, and 2,747 (3.6%) received both IABP and O-MCS. At the start of the study period, 45% of patients undergoing PCI in the setting of cardiogenic shock received an IABP and 6.7% received O-MCS. The proportion of patients receiving IABP declined at an average rate of 0.3% per quarter, while the rate of O-MCS use was unchanged over the study period. The predicted probability of IABP use varied significantly by site (hospital median 42%, interquartile range 33-51%, range 8-85%). The probability of O-MCS use was <5% for half of hospitals and >20% in less than one-tenth of hospitals.
Conclusions:
The authors concluded that use of IABP in the setting of PCI for cardiogenic shock decreased over time without a concurrent increase in O-MCS utilization.
Perspective:
This study reports a declining trend in IABP use over the study period, with no change in the rate of use of O-MCS. Despite a decreasing trend in IABP use, the rate of decline did not change following publication of the IABP-SHOCK II trial, which found no benefit of IABP in the setting of myocardial infarction. Furthermore, there was a significant hospital level and geographic variation in the use of IABP and O-MCS, with very few hospitals employing O-MCS technologies. Additional studies are indicated to look at the impact of new mechanical support devices on patient outcomes to guide the optimal use of these devices for PCI.
Keywords: Cardiac Catheterization, Intra-Aortic Balloon Pumping, Myocardial Infarction, National Cardiovascular Data Registries, Percutaneous Coronary Intervention, Shock, Cardiogenic
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