Use of intra-aortic balloon pump in cardiogenic shock: Evidence-based or experience-based? Insights from a historical, real life comparison

Abstract

The use of intra-aortic balloon pump (IABP) in ST-segment elevation myocardial infarction (STEMI) presenting in cardiogenic shock (CS) has recently been challenged by the pivotal study IABP SHOCK II trial (Thiele H et al. N Engl J Med 2012). Based on this trial, the ESC guidelines have relegated the use of IABP to class III recommendation in STEMI CS patients. This low level of recommendation does not necessarily apply to all forms of CS and IABP may still be considered valuable in selected patients. We thought of interest to assess the impact of the new guidelines on the use of IABP according to the CS etiology and to assess the impact of a potential change of practice on outcomes. Over a six year period, between January 2010 and January 2016, all consecutive CS admitted in intensive care unit in our University Hospital were included. CS were divided in 2 cohorts, historical cohort (HC, before pivotal study publication date, from 2010 to 2013) and contemporary cohort (CC, after pivotal study publication date, from 2013 to 2016). Analyses were performed in the whole cohort and in the 2 cohorts separately. 303 patients were included, 159 patients in HC and 144 in group CC. The two cohorts had very similar demographic characteristics and comorbidities. Etiologies of CS were also similar. IABP implantation rate was higher in the HC taken as a whole or by etiology. Importantly, in-hospital mortality was the same in the two cohorts 61 (38.6%) and 52 (36.1%), P = 0.37 in HC and CC, respectively. The IABP SHOCK trial has changed our practice concerning the management of CS: while the reduction of IABP in STEMI was expected, that on other etiology was not. This real-life study illustrates that physicians are able to rapidly change their practice. The outcomes were not affected by this IABP reduction, our study validates the results of the IABP SHOCK 2 trial and prompts us to further reduce its use in STEMI. This may have medico-economics impact.