P5733IABP use in patients with STEMI complicated by cardiogenic shock: time for rehabilitation?

Abstract

Abstract Background Evidence from a large randomized clinical trial has led international guidelines to downgrade to Class III the recommendation level for the routine use of intra-aortic balloon pump (IABP) in patients with STEMI complicated by cardiogenic shock (CS). Despite this, its use in clinical practice remains high. Purpose The aim of our study was to evaluate whether IABP use could provide a prognostic benefit in a large real-world population of STEMI patients undergoing primary PCI (pPCI). Methods Our registry included 2958 consecutive patients undergoing primary pPCI for STEMI in our department from 2005 to 2017. The presence of a persistent (>30 min) systolic blood pressure <90 mmHg and signs of pulmonary congestion or impaired end organ perfusion needing catecholamine infusion qualified for CS. Among patients with CS we compared mortality between those with and those without IABP in the whole population and in the pre-specified subgroup with anterior STEMI. Univariate (cross-tables and Kaplan-Meier curves with log-rank test) and multivariate mortality analysis (Cox regressions) were performed. Results CS occurred in 246 patients (8.3%); among these patients, 145 (60%) had anterior AMI. Mortality at 30 days was 3.7 in inferior vs 7.1% in anterior STEMI (p<0.001). In these two groups of patients, IABP was used in 32% and 66.7% of cases, respectively. In the whole CS group, IABP use was associated with a lower 30-day mortality (39% vs 53%, p=0.020 – see figure panel A); this figure was confirmed at multivariable analysis (HR 0.49, 95% CI 0.27–0.87, p=0.016) after adjusting for age, CK peak, triple-vessel disease, eGFR and all-TIMI bleeding during hospital stay. IABP use in CS patients was not associated with major complications or an increased rate of Hb drop (>3 mg/dL) during hospital stay. In the subgroup of patients with anterior STEMI, there was a marked survival benefit at univariate analysis (30-day mortality 41% vs 61%, p=0.013 – see figure panel B), confirmed at multivariable analysis (HR 0.40, 95% CI 0.19–0.88, p=0.023) after adjusting for the same variables of the previous model. In the subgroup of patients with inferior STEMI, IABP use was not significantly associated with a lower 30-day mortality (32% vs 41%, p=0.380). Figure 1 Conclusion In the present large real-world cohort of unselected patients with STEMI, the use of IABP in case of CS was found to improve survival. This finding suggests that IABP could still play a role in patient with STEMI complicated by CS, especially when additional risk features are present, such as anterior MI. We suggest that additional careful prospective studies are needed before abandoning or markedly limiting the use of IABP in this clinical setting.