Another Blow for Intra-Aortic Balloon Pumo Counterpulsation? Randomized Study on Its Use in Chronic Heart Failure Progressing to Cardiogenic Shock

Cardiogenic shock (CS) remains a condition with extremely high mortality (around 50%). While most therapies for this pathology have been studied in CS secondary to acute myocardial infarction (AMI), there is limited evidence regarding CS resulting from the progression of advanced chronic heart failure (also known as HF-CS).

Intra-aortic balloon pump (IABP) counterpulsation has been a commonly used strategy in cases of AMI. Its discouraging results have led European guidelines to give it a class III-B recommendation. In the case of HF-CS, data on its clinical impact are scarce and heterogeneous. Therefore, the group led by Morici et al. aimed to assess the effectiveness of early use of IABP conterpulsation in combination with standard treatment versus standard pharmacological therapy alone (with inotropes and vasopressors).

To do this, they conducted a multicenter randomized study named Altshock-2. It included 101 patients with HF-CS classified in stages B to D according to the classification by the Society for Cardiovascular Angiography and Interventions (SCAI). Participants were randomized 1:1 to either standard treatment or standard treatment plus IABP counterpulsation.

The primary endpoint was survival at 60 days or successful bridging to advanced cardiac replacement therapies (heart transplant or left ventricular assist device). After a predefined interim analysis, the study was stopped early for futility.

Read also: Percutaneous Tricuspid Valve Replacement with Lux-Valve.

There were no significant differences in the primary outcome between the two groups: 81% in the IABP counterpulsation group vs. 75% in the standard group (hazard ratio [HR]: 0.72; 95% confidence interval [CI]: 0.31–1.68; p=0.45). The need to escalate to more advanced mechanical circulatory support devices was also similar (7.5% with IABP counterpulsation vs. 4.2% with standard treatment).

There were also no differences in mortality or in secondary outcomes such as maximum inotropic support required or sequential organ failure assessment (SOFA). Complication rates (for bleeding, peripheral ischemia, or embolic events) were comparable between both groups.

Conclusion

In patients with advanced heart failure progressing to cardiogenic shock, routine early use of IABP counterpulsation in combination with standard treatment was not associated with a significant improvement in survival or in the likelihood of bridging to advanced therapies.

Original Title: Early Intra-Aortic Balloon Support for Heart Failure-Related Cardiogenic Shock 

Reference: Shah, A, Keene, S, Pennells, L. et al. Cardiac Troponins and Cardiovascular Disease Risk Prediction: An Individual-Participant-Data Meta-Analysis. JACC. 2025 Apr, 85 (14) 1471–1484. https://doi.org/10.1016/j.jacc.2025.02.016.