Evaluation of Intra-Aortic Balloon Support in cardiogenic shock.
Date First Published:
May 15, 2013
Last Updated:
February 26, 2014
Report by:
Dr. Joseph Humphrey and Dr Bryan Judge, Emergency Medicine Residents (Grand Rapids Medical Education Research Partners/Michigan State University, Michigan, USA)
Search checked by:
Bernard A Foex, Grand Rapids Medical Education Research Partners/Michigan State University, Michigan, USA
Three-Part Question:
In [adult patients with cardiogenic shock following myocardial infarction ] [what is the usefulness] of [intra-aortic balloon support]?
Clinical Scenario:
A 67-year-old man is brought to the emergency department. He is cold, clammy and confused. He is also hypotensive and an ECG shows that he has had an AMI with ST elevation. While your colleagues prepare some vasopressors you speak to the cardiologist on call. He suggests getting the patient to the cardiac cath lab to put in an IABP. You wonder whether there is any evidence to support this course of action?
Search Strategy:
Medline 1946-05/13 using OVID interface, Cochrane Library (2013), PubMed clinical queries
[(myocardial infarction.mp. or exp Myocardial Infarction/) AND (cardiogenic shock.mp. or exp Shock, Cardiogenic/) AND (exp Intra-Aortic Balloon Pumping/ or intra -aortic balloon pump.mp.)] Limit to English language and randomized controlled trial.
[(myocardial infarction.mp. or exp Myocardial Infarction/) AND (cardiogenic shock.mp. or exp Shock, Cardiogenic/) AND (exp Intra-Aortic Balloon Pumping/ or intra -aortic balloon pump.mp.)] Limit to English language and randomized controlled trial.
Outcome:
65 papers were identified; of which two recent RCTs answered the clinical question. A systematic review was also identified, which incorporated the RCT data. Two other RCTs were also identified. Only the most recent RCTs and the systematic review are presented.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Intraaortic balloon support for myocardial infarction with cardiogenic shock. Thiele H, Zeymer U, Neumann FJ, et al. 2012 Germany | All patients were adults who had acute myocardial infarction complicated by cardiogenic shock and were expecting to undergo early revascularization either by percutaneous coronary intervention or bypass grafting. | Randomized Clinical Trial | 30 day all-cause mortality | 119 Patients in the IABP group (39.7%) and 123 patients in the control group (41.3%) died (relative risk with IABP, 0.96; 95% CI 0.79 to 1.17, p=0.69) | The timing of intra-aortic balloon insertion was not controlled for. There was also 10% crossover of the control group to the intra-aortic balloon group. |
| Hemodynamic effects of intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock: the prospective, randomized IABP shock trial Prondzinsky R. Unverzagt S. Russ M et al. 2012 Germany | Adult patients with acute myocardial infarction complicated by cardiogenic shock who were treated with PCI, and required vasopressor/inotropic support after adequate volume filling. | Randomized controlled trial. | Primary: Change in APACHE II Score 4 days from enrollment | No differences among both groups for disease improvement(18.2 +/- 3.7 vs. 20.2 +/- 2.3 APACHE II score) | Low patient enrollment, only 40 patients in total, making the power of the study sufficiently low. |
| Secondary: Hemodynamic parameters (HR, SVR, MAP, CO) | No significant difference between IABP and medical treatment group. | ||||
| Secondary: Invasive hemodynamic parameters (cardiac power, LVSWI, PCWP) | No significant difference between IABP and medical treatment group. | ||||
| The outcome of intra-aortic balloon pump support in acute myocardial infarction complicated by cardiogenic shock according to the type of revascularisation: A comprehensive meta-analysis. Romeo F, Acconia MC, Sergi D, et al. 2013 Italy | 14, 186 patients from 17 studies of IABP therapy for cardiogenic shock. 13 of the studies were observational, only 4 were RCTs | Systematic review and meta-analysis | Overall in-hospital mortality with IABP | RR 0.95 (95% CI 0.83-1.10) p=0.52. | Analysis is dominated by the observational studies. The mortality rates for the three subgroups are very different: 83.9% for the no reperfusion subgroup, 66.9% for the thrombolysis subgroup, and 38.4% for the PCI subgroup. |
| No reperfusion subgroup, mortality with IABP | RR 0.83 (95% CI 0.65-1.05) p=0.13. | ||||
| Thrombolysis subgroup, mortality with IABP | RR 0.77 (95% CI 0.68-0.87) p<0.0001. | ||||
| PCI subgroup, mortality with IABP | RR 1.18 (95% CI 1.04-1.34) p=0.01. | ||||
| Longterm survival with IABP | RR 0.88 (95% CI 0.65-1.20) p=0.43 |
Author Commentary:
Two recent RCT have been performed to evaluate the clinical utility of intra-aortic balloon support for those patients with AMI complicated by cardiogenic shock. The IABP-Shock trial demonstrated no clinically significant benefit in a small, single-centre study addressing a change in APACHE II score. The IABP-Shock II trial was a much larger, multicentre RCT with a primary endpoint of mortality that still showed no significant clinical difference. The most recent meta-analysis (Romeo et al, 2013) suggests that the IABP may have a role when primary coronary intervention (PCI) will not be possible or as a bridge to delayed PCI or some other mechanical intervention.
Bottom Line:
The role of IABP support in patients with cardiogenic shock from myocardial infarction remains unclear, without evidence of clear confirmed benefit compared to conventional therapy, especially when PCI is available.
References:
- Thiele H, Zeymer U, Neumann FJ, et al. . Intraaortic balloon support for myocardial infarction with cardiogenic shock.
- Prondzinsky R. Unverzagt S. Russ M et al.. Hemodynamic effects of intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock: the prospective, randomized IABP shock trial
- Romeo F, Acconia MC, Sergi D, et al.. The outcome of intra-aortic balloon pump support in acute myocardial infarction complicated by cardiogenic shock according to the type of revascularisation: A comprehensive meta-analysis.
- O'Gara PT, Kushner FG, Ascheim DD, et al.. 2013 ACCF/AHA Guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
- Van de Werf F, Bax J, Betriu A, et al.. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation.