Intraaortic Balloon Support for Myocardial Infarction With Cardiogenic Shock

Study Questions:

What is the impact of intra-aortic balloon counterpulsation (IABP) on mortality among patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization is planned?

Methods:

In this randomized, prospective, open-label, multicenter trial, the investigators randomly assigned 600 patients with cardiogenic shock complicating acute myocardial infarction to IABP (IABP group, 301 patients) or no IABP (control group, 299 patients). All patients were expected to undergo early revascularization (by means of percutaneous coronary intervention or bypass surgery) and to receive the best available medical therapy. The primary efficacy endpoint was 30-day all-cause mortality. Safety assessments included major bleeding, peripheral ischemic complications, sepsis, and stroke.

Results:

A total of 300 patients in the IABP group and 298 in the control group were included in the analysis of the primary endpoint. At 30 days, 119 patients in the IABP group (39.7%) and 123 patients in the control group (41.3%) had died (relative risk with IABP, 0.96; 95% confidence interval, 0.79-1.17; p = 0.69). There were no significant differences in secondary endpoints or in process-of-care measures, including the time to hemodynamic stabilization, the length of stay in the intensive care unit, serum lactate levels, the dose and duration of catecholamine therapy, and renal function. The IABP group and the control group did not differ significantly with respect to the rates of major bleeding (3.3% and 4.4%, respectively; p = 0.51), peripheral ischemic complications (4.3% and 3.4%, p = 0.53), sepsis (15.7% and 20.5%, p = 0.15), and stroke (0.7% and 1.7%, p = 0.28).

Conclusions:

The authors concluded that the use of IABP did not significantly reduce 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction.

Perspective:

In this large, randomized trial involving patients with cardiogenic shock complicating acute myocardial infarction, for whom early revascularization was planned, IABP support did not reduce 30-day mortality. Furthermore, there was a lack of significant between-group differences in multiple secondary endpoints and process-of-care outcomes. Further assessments at 6 months and at 12 months are indicated to corroborate these 30-day findings. However, given the concordance of data from prior meta-analyses and the current trial, the evidence does not appear to support the routine use of IABP in patients with acute myocardial infarction complicated by cardiogenic shock.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support

Keywords: Risk, Myocardial Infarction, Stroke, Sepsis, Counterpulsation, Angioplasty, Balloon, Coronary, Hemodynamics, Percutaneous Coronary Intervention, Shock, Cardiogenic, Heart Failure, Cardiovascular Diseases, Confidence Intervals, Intra-Aortic Balloon Pumping, Lactic Acid, Hemorrhage


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