Recurrent or Refractory Ischemia

Patients unresponsive to medical management with continued ischemia should be treated on an individual basis. Depending on the infarct distribution and coronary anatomy, decisions could be made regarding continued medical management, rescue angioplasty, or coronary artery bypass grafting. Emergency cardiology referral should be considered. Refractory ischemia is often investigated with coronary catheterization.

Intraaortic balloon counterpulsation delivers phased pulsations synchronized to the electrocardiograph so that balloon inflation will occur at the time of aortic valve closure and deflation occurs just prior to onset of systole. The augmented coronary perfusion pressure during diastole enhances coronary blood flow. Balloon deflation during systole allows the left ventricle to eject blood against a lower resistance. The net effect of intra-aortic balloon counterpulsation is an increase in cardiac output, reduction in systolic arterial pressure, increase in diastolic arterial pressure, little change in mean arterial pressure, and reduction in heart rate. The reduction in left ventricular afterload leads to reduced myocardial oxygen consumption, decreasing the amount of myocardial ischemia. Intraaortic balloon counterpulsation is recommended for patients with ACS who are refractory to aggressive medical management or are hemodynamically unstable, as a means to bridge a patient's stability en route to the cardiac catheterization laboratory or the operating room. 24

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