Original title: Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock (for the IABP-Shock II Trial Investigator) Reference: Holger T, et al. NEJM 367;14:1287

The rate of mortality in cardiogenic shock secondary to acute myocardial infarction (AMI) is high even in patients receiving early revascularization. The use of an intra-aortic balloon counter-pulsation pump (IABP) according to the guidelines of the U.S. and Europe ranks as a class IB or IC respectively. 

The aim of this study was to evaluate whether the use of IABP versus the best available therapy resulted in a reduction of mortality in patients with acute myocardial infarction in cardiogenic shock. This study randomized 300 patients (PT) in the IABP group and 298 in the control group between June 2009 and March 2012 in 37 centers in Germany.

PT with AMI was included, (with or without ST segment elevation), complicated with cardiogenic shock and planning for an early revascularization, (PCTA or CABG). Cardiogenic shock was considered at a systolic pressure of 90 mmHg, clinical signs of pulmonary congestion or signs of poor peripheral perfusion. 

Eligible PT was randomized 1:1 to IABP versus the control group. The revascularization procedure was PCTA, PCTA which was applied in two stages and myocardial revascularization surgery, procedures left to the discretion of the surgeon. 

The primary endpoint was all-cause mortality at 30 days. There was no difference in the clinical characteristics of both groups. The IABP was implanted before or immediately after the PCTA. In the control group 10% of PT, IABP was placed within the first 24 hours after randomization and 13 PT randomized IABP group did not receive placement because they died. The most common procedure was revascularization PCTA, (95.8%).There was no significant difference at 30 days in the primary endpoint, (39.7% versus 43.3% p = 0.69).

Conclusion 

The use of IABP does not reduce mortality significantly in PT presenting AMI complicated by cardiogenic shock with an early revascularization strategy within 30 days.

Editorial Comment:

Cardiogenic shock complicating AMI is a serious event with a high mortality rate and requires quick decisions. Although this randomized study had a significant number of PT, the use of IABP did not present favorable results. It should be noted that in the control group 10% of PT received IABP within 24 hours of admission but the medical treatment was not enough to stabilize them. The IABP was implanted before or after PCTA, perhaps early implantation helped to reduce complications. To treat this complication and decrease the mortality rate there is a need for new technologies.

Courtesy of Carlos Fava, MD
Interventional cardiologist
Hospital Universitario Favaloro 

Dr. Carlos Fava para SOLACI.ORG