715-2 A Prospective, Randomized Trial Evaluating the Prophylactic Use of Balloon Pumping in High Risk Myocardial Infarction Patients: PAMI-2

Abstract

Myocardial infarction (MI) patients with advanced age, multivessel disease or ventricular dysfunction continue to have a poor prognosis despite reperfusion therapy. Furthermore, the majority of deaths from MI occur within the first 48 hours, thus risk stratification and therapeutic interventions ideally should occur acutely. The PAMI-2 study has prospectively evaluated the hypotheses that 1) emergency catheterization with primary PTCA may allow acute risk stratification and 2) clinical outcome, ventricular function and infarct vessel patency will be improved by balloon pumping in patients identified to be high risk. MI patients who presented 0–12 hrs underwent emergency catheterization and PTCA and were stratified as high risk if one of the following was present: age>70 yrs, vein graft occlusion, 3 vessel disease, ejection fraction <45%, suboptimal PTCA result or if malignant arrhythmias persisted post PTCA. High risk patients were randomized to receive or not receive an intra aortic balloon pump (IABP) for 48 hrs. Catheterization was repeated at day 7 to determine infarct vessel patency and improvement in ventricular function. At 6 weeks a rest and exercise radionuclide ventriculogram was performed. To date, 320 patients have been enrolled, 175 of which have complete data available for analysis. The reasons for high risk status include: advanced age 38%, poor LV function 55%, 3 vessel disease 37%, vein graft occlusion 6%, suboptimal PTCA 9%, and arrhythmias 5%. Despite the high risk status, in-hospital outcomes have been favorable: death 2.9%, recurrent MI 5.8%, stroke 1.2%, angiographic reocclusion 5.8%, heart failure 19.1% and combined events 26.6%. Thus “high risk” patients treated with primary PTCA ± balloon pumping appear to have a good prognosis. Whether the improved outcome is due to balloon pump support or simply due to aggressive mechanical revascularization will be determined in the entire cohort by March 1995.