Myocardial infarction: cardiogenic shock: balloon counterpulsation was not clearly helpful

Clinical bottom line (level 2b-)

  1. Patients with cardiogenic shock from an acute myocardial infarction who received early insertion of intraaortic balloon counterpulsation, ware not clearly less likely to die.
Anderson et al: Journal of the American College of Cardiology 1997; 30 (3): 708-715
Expires October 2003

The study

Inception cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.
Setting: acute hospitals, worldwide

310 patients (aged mean 66 years, 63% male) with cardiogenic shock from an acute myocardial infarction

Excluded if
  • non-compressible punctures
  • previous stroke
  • active bleeding
  • previous treatment with streptokinase or anistreplase
  • recent trauma or major operation


    • Control Group: (n = 248, 248 analysed): no intraaortic balloon counterpulsation
    Experimental Group: (n = 62, 62 analysed): early insertion of intraaortic balloon counterpulsation
    All patients received aspirin, thrombolysis with streptokinase or alteplase, and iv atenolol. Nitrates, antiarrhythmics, calcium-channel blockers, ACE inhibitors and digitalis were prescribed if required.
    100% followed for 30 days Outcomes were adjusted for confounding clinical predictors of mortality.
    Outcome notes:
    • death : at 30 days

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    death 30 days 149
    (60.1%)    		 29
    (46.8%)    		 22%
    (-3% to 41%)    		 13.3%
    (-0.53% to 27.1%)    		 8
    (NNT = 4 to infinity;
    NNH = 190 to infinity)

    Comments

    1. Patients who had cardiogenic shock were on average four years younger, more likely to be American (with possible other management strategies used) and were more likely to have received inotropic agents, cardioversion, PTCA or CABG.
    2. The most important lesson from this study is that IABP is not obviously an inferior therapy and this should stimulate a more proper comparison in the future.

    Citation

    1. Anderson RD, Ohman EM, Holmes DR, et al: Use of intraaortic balloon counterpulsation in patients presenting with cardiogenic shock: observations from the GUSTO-I study. Journal of the American College of Cardiology 1997; 30 (3): 708-715
    Contributor: Chris Ball and Clare Wotton, October 1999
    Reviewer: Christian Torp-Pedersen

    Clinical Question.
    Patient cardiogenic shock
    Intervention or Exposure intraaortic balloon counterpulsation
    Outcome death