Elsevier

The American Journal of Cardiology

Volume 191, 15 March 2023, Pages 125-132
The American Journal of Cardiology

Trends in Intra-Aortic Balloon Pump Use in Cardiogenic Shock After the SHOCK-II Trial

https://doi.org/10.1016/j.amjcard.2022.12.019Get rights and content

Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularization. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the IABP-SHOCK-II (Intra-aortic Balloon Pump in Cardiogenic Shock-II study) trial found no survival benefit. We aimed to determine the trends in IABP use in patients who underwent percutaneous intervention over time. Data were taken from patients in the Melbourne Interventional Group registry (2005 to 2018) with MI-CS who underwent percutaneous intervention. The primary outcome was the trend in IABP use over time. The secondary outcomes included 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCEs). Of the 1,110 patients with MI-CS, IABP was used in 478 patients (43%). IABP was used more in patients with left main/left anterior descending culprit lesions (62% vs 46%), lower ejection fraction (<35%; 18% vs 11%), and preprocedural inotrope use (81% vs 73%, all p <0.05). IABP use was associated with higher bleeding (18% vs 13%) and 30-day MACCE (58% vs 51%, both p <0.05). The rate of MI-CS per year increased over time; however, after 2012, there was a decrease in IABP use (p <0.001). IABP use was a predictor of 30-day MACCE (odds ratio 1.6, 95% confidence interval 1.18 to 2.29, p = 0.003). However, IABP was not associated with in-hospital, 30-day, or long-term mortality (45% vs 47%, p = 0.44; 46% vs 50%, p = 0.25; 60% vs 62%, p = 0.39). In conclusion, IABP was not associated with reduced short- or long-term mortality and was associated with increased short-term adverse events. IABP use is decreasing but is predominately used in sicker patients with greater myocardium at risk.

Section snippets

Methods

Data from consecutive patients enrolled in the Melbourne Interventional Group (MIG) registry presenting with MI (ST-elevation MI [STEMI] or non-STEMI) complicated by CS who underwent PCI from January 2005 to December 2018 and who had 30-day follow up were analyzed. Patients who received thrombolysis were excluded. VA-ECMO data were only available from 2015 to 2018. The Impella device (ABIOMED, Danvers, Massachusetts) was not available for use in this jurisdiction during this study.

The MIG

Results

Between January 2005 and December 2018, 1,110 patients presented with MI-CS and underwent PCI. An IABP was implanted in 478 patients (43%). Baseline characteristics are presented in Table 1. Patients managed with IABP were more likely to have pre-existing heart failure before IABP (39% vs 26%, p <0.001). The rates of STEMI were similar between groups (89% vs 90%, p = 0.70), with only 10% presenting with non-STEMI overall. The concomitant out-of-hospital cardiac arrest rates were similar between

Discussion

Patients with MI-CS who underwent PCI remain a high-risk group associated with significant mortality. The initial uptake of the IABP was swift after early observational data demonstrating mortality benefit across a range of indications, including MI-CS, to support high-risk PCI or coronary artery bypass graft and after thrombolysis.9, 10, 11 A critical mass of evidence accumulated, culminating in the SHOCK-II trial that surprisingly demonstrated no mortality benefit of IABP use as a temporary

Disclosures

DS research is supported by a National Heart Foundation fellowship and a National Health and Medical Research Council's (NHMRC) Investigator Grant. The remaining authors have no conflicts of interest to declare.

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    • Cited by (4)

    Drs. Stub and Duffy contributed equally as senior authors.

    Funding: The Melbourne Interventional Group acknowledges funding from Abbott Vascular (Chicago, Illinois), AstraZeneca (Cambridge, United Kingdom), Bristol-Myers Squibb (New York, New York), and Pfizer (New York, New York). These companies do not have access to data and do not have the right to review manuscripts or abstracts before publication.

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