October - 2012
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Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shockthe IABP-SHOCK II Trial Investigators N Engl J Med, 2012, 367:1287-1296 This page is only available to Crit-IQ subscribers. To view the rest of this review and gain access to our vast array of critical care teaching tools including podcasts, vodcasts, modules, exam preparation tools, teaching aids and much more, login here, or Become a Member to register |
October |
Previous Comments
| There doesn't seem to be a lot of evidence supporting IABP use in this context. A meta-analysis published in 2008 showed no difference in outcomes, though the evidence was pretty patchy (http://eurheartj.oxfordjournals.org/content/30/4/459.full). This paper seems to support that. | |
| Dan-31 Aug, 2012 11:19:47 AM | |
| Its one of those things though isn't it. A bit like Xigris, despite the evidence, people will use it because we don't have much else, right up until the point there is conclusive proof its useless. Are we at that point? I suspect not - I would imagine plenty of pumps will still be placed in this context, despite this paper. | |
| Todd Fraser-31 Aug, 2012 11:30:06 AM | |
| ~97% of patients had coronary revascularisation,this trial cannot be generalised to institutions, where IABP can be done but not revascularisation. | |
| sid-03 Sep, 2012 07:25:17 PM | |
| Absolutely agree Sid. Many institutions might not have revascularisation immediately available, but would transfer for this purpose. This might expose the heart to significant hypoperfusion for a prolonged period, and IABP might mitigate this. The unknown group is those who do not undergo revascularisation at all. Is there evidence in this group? | |
| Angus-04 Sep, 2012 10:32:47 AM | |
| Yes, i agree it still remains unanswered whether it is beneficial in those group of patients who donot/cannot undergo revascularisation. With no difference in complications compared to control group IABP maintains "do no harm" with atleast some potential benefit (?evidence) in those who donot/cannot undergo early revascularisation. | |
| Mahadev-10 Sep, 2012 03:18:58 PM | |
| The issue of IABP in patients with delayed revascularisation was specifically not included in this study, and remains unanswered. It is unlikely to be until a similar delayed therapy trial in conducted, probably a very difficult study as patients would need to be enrolled and intervened on in non-PCI centres. The possibility that IABPs are ineffective, including in delayed settings, will remain. The assumption that what we are doing is right until proven otherwise seems we are generally reluctant to abandon an unproven standard practice until there is evidence of harm or lack of efficacy, in contrast to new therapies that need evidence of benefit. So I have some questions; 1. Why were IABPs only put in 25-40% of the time in urgent PCI settings prior to this study? 2. If we dont change our practice in urgent PCI following this study, what will it take? 3. If we are not prepared to apply this study to delayed PCI, should we encourage an RCT to resolve it? 4. Is it simply OK to just do our own thing? A lecture in NEJM covers the issues around translational research really well. (http://www.nejm.org/doi/full/10.1056/NEJMsa035507 ) | |
| Neil Orford-11 Sep, 2012 12:03:05 PM | |
| I know some centres use VA ECMO for essentially unsupportable cardiogenic shock in the young after PCI but in my (one year only) experience these patients all died or received a transplant. I think we might have to accept that you can indeed die of a broken heart. | |
| Andrew Stapleton-30 Oct, 2012 11:06:06 AM | |
| Receiving a heart transplant seems like a pretty good outcome to me... | |
| Florence Nightingale-30 Oct, 2012 04:43:56 PM | |
| IABP is used as form of support for Cardiogenic shock, similar to ventilators for respiratory failue or dialysis for renal failure. These forms of support are initiated and despite the support some patients will die. Do you then go on to say that those interventions were ineffective and hence should not be used?? I think thats unwise and imprudent. Based on this study would you stop using IABP? I dont think this will actually change practice. I doubt IABPs were ever intended to magically improve outcomes. They are used to SUPPORT (not really a therapy with curative properties) a patient prior to CAGS or to support the heart following an acute coronary event with cardiogenic shock, awaiting PCI and post PCI to improve coronary flow. The patient selection is the main determinant of mortality and NOT because IABP wasn't effective. So what would the alternative be? Inotropes which may affect myocardial supply/demand, ECMO, VAD or transplant? What is the outcomes with all those interventions ? What are the logistics involved? From the arguments and comments it seems we should not intervene !! After all cardiogenic shock has a huge mortality. Close to 80 to 90% of those patients die anyway! Do we just accept that and let those patients die? My practice will not change. I doubt any trial will be able to clarify this dilemma. | |
| surprised!!-27 Nov, 2012 11:10:46 PM | |
| IABP is a support for the "failing heart". The question one must ask before intitating IABP is if there is something reversible and if in reversing that problem, will the patient benefit and make a good recovery ie acute MI with minimal myocardial injury where coronary flow can be effectively restored and myocardium salvaged. If that can be achieved, would you deny a patient IABP support because the trial has not shown any survival benefit? I think that would be bad medicine ! If on the other hand the patient is of an extreme age with bad vascular disease, poor general health, renal failure etc, I am sure such patient would certainly not be a candidate for IABP. Thus it comes down to the type of patient and good clinical judgement in patient selection that determines the outcomes NOT the intervention or the support system. | |
| surprised!!-27 Nov, 2012 11:26:40 PM | |
| With that approach, obviously not all perfectly or close to perfectly selected patients will benefit. A proportion of them will have bad outcomes too for various reasons. But I am sure the numbers benefitting will be far in excess of what the trial is suggesting. | |
| surprised!!!-27 Nov, 2012 11:30:03 PM | |
Comment
This article was published in the NEJM online last month, and is the focus of this weeks NEJM.
Is this a game changer? With 600 patients in a RCT of IABP in cardiogenic shock, there is unlikley to be a bigger trial soon...
Mortality in patients with cardiogenic shock requiring PCI or...