The outcomes of intra-aortic balloon pump usage in patients with acute myocardial infarction: a comprehensive meta-analysis of 33 clinical trials and 18,889 patients

Figures & data

Figure 1 A flowchart depicting the selection of the studies included in this meta-analysis.

Table 1 The characteristics of randomized controlled trials pertaining to the use of an intra-aortic balloon pump in the setting of AMI

Study	Publication year	Type of reperfusion for AMI	Inclusion criteria	Excluded CS	Follow-up duration (d)
Waksman et al^Citation20	1993	Thrombolysis	AMI with CS	No	360
TACTICS^Citation19	2005	Thrombolysis, RV	AMI with hypotension or severe HF	No	30, 180
Li et al^Citation27	2007	RV	AMI with CS	No	360
SHOCK Trial^Citation28	2010	ERV	AMI with CS	No	In-hospital
IABP-SHOCK II^Citation7,Citation8	2013	ERV	AMI with CS	No	30, 360
O’Rourke et al^Citation22	1981	No reperfusion	AMI with acute HF	NA	450
Flaherty et al^Citation15	1985	No reperfusion	AMI without CS	Yes	14, 60
Ohman et al^Citation21	1994	ERV	AMI without CS	Yes	In-hospital
Kono et al^Citation23	1996	Failed thrombolysis	AMI without CS	Yes	30
PAMI-II^Citation24	1997	ERV	AMI without CS	Yes	In-hospital
Vijayalakshmi et al^Citation26	2007	ERV	AMI without CS	Yes	30
Gu et al^Citation29	2011	ERV	AMI without CS	Yes	30, 180
CRISP AMI^Citation30	2011	ERV	AMI without CS	Yes	30, 180
BCIS-1^Citation10	2013	ERV	AMI without CS	Yes	1,530
Van’t Hof et al^Citation25	1999	ERV	AMI with ST↑/↓>20 mm	NA	180

Abbreviations: AMI, acute myocardial infarction; CS, cardiogenic shock; d, days; ERV, emergency revascularization; HF, heart failure; NA, not available; RV, revascularization, including percutaneous transcoronary angioplasty and coronary artery bypass grafting; ST, ST-segments.

Table 2 The characteristics of observational trials pertaining to the use of an intra-aortic balloon pump in the setting of AMI

Study	Publication year	Type of reperfusion for AMI	Inclusion criteria	Excluded CS	Follow-up duration (d)
Moulopoulos et al^Citation31	1986	No reperfusion	AMI with CS	No	In-hospital
Bengtson et al^Citation32	1992	NA	AMI with CS	No	In-hospital
Stomel et al^Citation33	1994	Thrombolysis, ERV	AMI with CS	No	In-hospital
Kovack et al^Citation35	1997	Thrombolysis	AMI with CS	No	30, 360
GUSTO-I^Citation34	1997	Thrombolysis, RV	AMI with CS	No	30, 360
SHOCK Trial Registry^Citation38	2000	Thrombolysis, ERV	AMI with suspected CS	No	In-hospital
NRMI-2^Citation39	2001	Thrombolysis, ERV	AMI with CS	No	In-hospital
French et al^Citation40	2003	Thrombolysis, ERV	AMI with CS	No	360
Gu et al^Citation41	2010	ERV	AMI with CS	No	30, 180
Stub et al^Citation43	2011	RV	ACS with CS	No	30
EHS PCI Registry^Citation42	2011	ERV	AMI with CS	No	In-hospital
AMC CS^Citation49	2012	ERV	AMI with CS	No	30
ALKK-PCI Registry^Citation45	2013	ERV	AMI with CS	No	In-hospital
Dziewierz et al^Citation46	2014	ERV	AMI with CS	No	30, 360
Ohman et al^Citation16	1991	Thrombolysis	AMI without CS	Yes	In-hospital
Mahmoudi et al^Citation44	2012	ERV	AMI without CS	Yes	In-hospital
Brodie et al^Citation36	1999	ERV	AMI without prior TT	NA	30
Kumbasar et al^Citation37	1999	Thrombolysis	AMI ≤6 h	NA	In-hospital

Abbreviations: AMI, acute myocardial infarction; CS, cardiogenic shock; d, days; ERV, emergency revascularization; h, hours; NA, not available; RV, revascularization, including percutaneous transcoronary angioplasty and coronary artery bypass grafting; TT, thrombolytic therapy.

Table 3 The baseline characteristics of randomized controlled trials pertaining to the use of an IABP in the setting of AMI

Study	Patients, N (IABP/control)	Mean age, years (IABP/control)	Male, n (IABP/control)	Hypertension, n (IABP/control)	Diabetes, n (IABP/control)	Prior MI, n (IABP/control)
Waksman et al^Citation20	24/21	66.8/67.8	14/15	14/10	NA/NA	15/11
TACTICS^Citation19	30/27	68*/67*	23/20	NA/NA	9/3	12/5
Li et al^Citation27	20/19	67.4/64.9	12/12	NA/NA	9/8	NA/NA
SHOCK Trial^Citation28	19/21	62.1/66.1	14/17	8/10	10/10	4/5
IABP-SHOCK II^Citation8	299/296	70*/69*	202/211	213/199	105/90	71/61
O’Rourke et al^Citation22	14/16	60/54	12/12	NA/NA	NA/NA	2/5
Flaherty et al^Citation15	10/10	52/53	9/8	NA/NA	NA/NA	4/4
Ohman et al^Citation21	96/86	56/55	71/65	47/37	16/15	19/20
Kono et al^Citation23	23/22	54/60	20/16	10/13	6/6	NA/NA
PAMI-II^Citation24	211/226	64.7/63.7	158/170	116/126	45/33	45/49
Vijayalakshmi et al^Citation26	17/16	57.5/59	14/14	6/6	3/4	2/4
Gu et al^Citation29	51/55	67.4/66.6	29/36	35/33	18/19	2/3
CRISP AMI^Citation30	156/173	56.1*/57.7*	132/144	39/60	27/36	0/0
BCIS-1^Citation9,Citation10	151/150	71/71	122/117	95/91	56/50	113/108
Van’t Hof et al^Citation25	118/120	59/56	99/101	NA/NA	12/9	17/16

Note:

* Median.

Abbreviations: AMI, acute myocardial infarction; IABP, intra-aortic balloon pump; MI, myocardial infarction; NA, not available.

Table 4 The baseline characteristics of observational clinical trials pertaining to the use of an IABP in the setting of AMI

Study	Patients, N (IABP/control)	Mean age, years (IABP/control)	Male, n (IABP/control)	Hypertension, n (IABP/control)	Diabetes, n (IABP/control)	Prior MI, n (IABP/control)
Moulopoulos et al^Citation31	35/14	60.3/61.1	29/13	NA/NA	NA/NA	6/16
Bengtson et al^Citation32	99/101	64/67	NA/NA	NA/NA	NA/NA	NA/NA
Stomel et al^Citation33	51/13	66/66	23/8	31/6	11/3	16/2
Kovack et al^Citation35	27/19	62/64	16/12	10/11	7/5	6/1
GUSTO-I^Citation34	62/248	64*/68*	42/154	23/99	14/57	19/67
Shock Registry^Citation38	439/417	65.2/73.4	294/250	203/233	137/141	154/188
NRMI-2^Citation39	4,215/4,456	~67/74.1	~60.5%/50.5%	~47%/49%	~29%/32%	~26%/30%
French et al^Citation40	260/41	65.3/67.4	175/30	124/17	83/10	84/14
Gu et al^Citation41	43/48	70.4/67.9	27/31	30/32	17/17	NA/NA
Stub et al^Citation43	251/159	65.7/67.7	189/110	142/99	71/39	54/38
EHS PCI Registry^Citation42	162/491	65.3/65.4	110/335	95/316	44/138	58/136
AMC CS^Citation49	199/93	64.7/61.5	136/61	69/29	36/16	60/22
ALKK-PCI Registry^Citation45	487/1,426	67.7/69.9	372/970	359/1,084	159/462	171/549
Dziewierz et al^Citation46	30/21	64.5*/72*	25/8	NA/NA	8/1	8/4
Ohman et al^Citation16	85/725	58/56	69/580	40/297	17/102	21/87
Mahmoudi et al^Citation44	70/70	~59/60.6	~71.4%/69.2%	~73.9%/80%	~21.9%/27%	~12.4%/9.6%
Brodie et al^Citation36	213/1,277	NA/NA	126/916	NA/NA	23/85	56/229
Kumbasar et al^Citation37	25/20	53.4/53.5	22/17	9/10	10/5	NA/NA

Note:

* Median.

Abbreviations: AMI, acute myocardial infarction; IABP, intra-aortic balloon pump; MI, myocardial infarction; NA, not available.

Figure 2 Forest plots of the primary efficacy endpoint of the included trials.

Notes: The odds ratio (OR) of in-hospital all-cause mortality (A), midterm all-cause mortality (B), and long-term all-cause mortality (C), associated with IABP use compared with no IABP use, stratified by different dual regimens. Weights are from random effects analysis.
Abbreviations: CI, confidence interval; IABP, intra-aortic balloon pump; RCT, randomized controlled trial; ID, identification.

Figure 3 Forest plots of the secondary efficacy endpoint of the included trials.

Notes: The odds ratio (OR) of reinfarction (A), recurrent ischemia (B), and new heart failure (C) associated with IABP use versus no IABP use stratified by different dual regimens. Weights are from random effects analysis.
Abbreviations: CI, confidence interval; IABP, intra-aortic balloon pump; RCT, randomized controlled trial; ID, identification.

Figure 4 Forest plots of the safety endpoints of the included trials.

Notes: The odds ratio (OR) of severe bleeding requiring blood transfusion (A) and stroke (B) associated with IABP use versus no IABP use stratified by different dual regimens. Weights are from random effects analysis.
Abbreviations: CI, confidence interval; IABP, intra-aortic balloon pump; RCT, randomized controlled trial; ID, identification.

Figure 5 Forest plots of the subgroup analysis of the included trials.

Notes: The odds ratio (OR) of in-hospital all-cause mortality (A) and long-term all-cause mortality (B) among the patients suffering from AMI complicated by CS, as well as midterm all-cause mortality (C) and the long-term mortality associated with different opportunities of IABP insertion vs no IABP use (D) according to reperfusion strategy and IABP insertion associated with IABP use versus no IABP use stratified by different dual regimens. (C) #: Different groups of patients from the TACTICS trial received the corresponding reperfusion; ##: different groups of patients from the GUSTO-I trial received the corresponding reperfusion. Weights are from random effects analysis.
Abbreviations: AMI, acute myocardial infarction; CI, confidence interval; ERV, emergency revascularization; TT, thrombolytic therapy; CS, cardiogenic shock; IABP, intra-aortic balloon pump; ID, identification; NA, not available.

WaksmanRWeissATGotsmanMSHasinYIntra-aortic balloon counterpulsation improves survival in cardiogenic shock complicating acute myocardial infarctionEur Heart J199314171748432295

 PubMed Web of Science ®Google Scholar

OhmanEMNanasJStomelRJThrombolysis and counterpulsation to improve survival in myocardial infarction complicated by hypotension and suspected cardiogenic shock or heart failure: results of the TACTICS TrialJ Thromb Thrombolysis2005191333915976965

 PubMed Web of Science ®Google Scholar

LiJLXueHWangBSEffect of prolonged intra-aortic balloon pumping in patients with cardiogenic shock following acute myocardial infarctionMed Sci Monit2007136R270R274

 Web of Science ®Google Scholar

ProndzinskyRLemmHSwyterMIntra-aortic balloon counter-pulsation in patients with acute myocardial infarction complicated by cardiogenic shock: The prospective, randomized IABP SHOCK Trial for attenuation of multiorgan dysfunction syndromeCritical Care Med201038115216019770739

 PubMed Web of Science ®Google Scholar

ThieleHZeymerUNeumannFJIntraaortic balloon support for myocardial infarction with cardiogenic shockN Engl J Med201236714128722920912

 PubMed Web of Science ®Google Scholar

ThieleHZeymerUNeumannFJIntra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trialLancet201338299051638164524011548

 PubMed Web of Science ®Google Scholar

O’RourkeMFNorrisRMCampbellTJChangVPSammelNLRandomized controlled trial of intraaortic balloon counterpulsation in early myocardial infarction with acute heart failureAm J Cardiol19814748158207010976

 PubMed Web of Science ®Google Scholar

FlahertyJTBeckerLCWeissJLResults of a randomized prospective trial of intraaortic balloon counterpulsation and intravenous nitroglycerin in patients with acute myocardial infarctionJ Am Coll Cardiol1985624344463926848

 PubMed Web of Science ®Google Scholar

OhmanEMGeorgeBSWhiteCJUse of aortic counterpulsation to improve sustained coronary artery patency during acute myocardial infarction. Results of a randomized trial. The Randomized IABP Study GroupCirculation19949027927998044950

 PubMed Web of Science ®Google Scholar

KonoTMoritaHNishinaTAortic counterpulsation may improve late patency of the occluded coronary artery in patients with early failure of thrombolytic therapyJ Am Coll Cardiol19962848768818837563

 PubMed Web of Science ®Google Scholar

StoneGWMarsaleseDBrodieBRA prospective, randomized evaluation of prophylactic intraaortic balloon counterpulsation in high risk patients with acute myocardial infarction treated with primary angioplasty. Second Primary Angioplasty in Myocardial Infarction (PAMI-II) Trial InvestigatorsJ Am Coll Cardiol1997297145914679180105

 PubMed Web of Science ®Google Scholar

VijayalakshmiKKunadianBWhittakerVJIntra-aortic counter-pulsation does not improve coronary flow early after PCI in a high-risk group of patients: observations from a randomized trial to explore its mode of actionJ Invasive Cardiol200719833934617712202

 PubMedGoogle Scholar

GuJHuWXiaoHProphylactic intra-aortic balloon pump reduces C-reactive protein levels and early mortality in high-risk patients undergoing percutaneous coronary interventionActa Cardiol201166449950421894807

 PubMed Web of Science ®Google Scholar

PatelMRSmallingRWThieleHIntra-aortic balloon counter-pulsation and infarct size in patients with acute anterior myocardial infarction without shock: the CRISP AMI randomized trialJAMA2011306121329133721878431

 PubMed Web of Science ®Google Scholar

PereraDStablesRClaytonTLong-term mortality data from the balloon pump-assisted coronary intervention study (BCIS-1): a randomized, controlled trial of elective balloon counterpulsation during high-risk percutaneous coronary interventionCirculation2013127220721223224207

 PubMed Web of Science ®Google Scholar

Van’t HofAWLiemALde BoerMJHoorntjeJCSuryapranataHZijlstraFA randomized comparison of intra-aortic balloon pumping after primary coronary angioplasty in high risk patients with acute myocardial infarctionEur Heart J199920965966510208786

 PubMed Web of Science ®Google Scholar

MoulopoulosSStamatelopoulosSPetrouPIntraaortic balloon assistance in intractable cardiogenic shockEur Heart J1986753964033732287

 PubMed Web of Science ®Google Scholar

BengtsonJRKaplanAJPieperKSPrognosis in cardiogenic shock after acute myocardial infarction in the interventional eraJ Am Coll Cardiol1992207148214891452920

 PubMed Web of Science ®Google Scholar

StomelRJRasakMBatesERTreatment strategies for acute myocardial infarction complicated by cardiogenic shock in a community hospitalChest1994105499710028162800

 PubMed Web of Science ®Google Scholar

KovackPJRasakMABatesEROhmanEMStomelRJThrombolysis plus aortic counterpulsation: improved survival in patients who present to community hospitals with cardiogenic shockJ Am Coll Cardiol1997297145414589180104

 PubMed Web of Science ®Google Scholar

AndersonRDOhmanEMHolmesDJUse of intraaortic balloon counterpulsation in patients presenting with cardiogenic shock: observations from the GUSTO-I Study. Global Utilization of Streptokinase and TPA for Occluded Coronary ArteriesJ Am Coll Cardiol19973037087159283530

 PubMed Web of Science ®Google Scholar

SanbornTASleeperLABatesERImpact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?J Am Coll Cardiol2000363 Suppl A1123112910985715

 PubMed Web of Science ®Google Scholar

BarronHVEveryNRParsonsLSThe use of intra-aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: Data from the National Registry of Myocardial Infarction 2Am Heart J2001141693393911376306

 PubMed Web of Science ®Google Scholar

FrenchJKFeldmanHAAssmannSFInfluence of thrombolytic therapy, with or without intra-aortic balloon counterpulsation, on 12-month survival in the SHOCK trialAm Heart J2003146580481014597928

 PubMed Web of Science ®Google Scholar

GuJHuWXiaoHFengXChenYZhangDIntra-aortic balloon pump improves clinical prognosis and attenuates C-reactive protein level in acute STEMI complicated by cardiogenic shockCardiology20101171758020924182

 PubMed Web of Science ®Google Scholar

StubDChanWClarkDAre intra-aortic balloon pumps harmful in cardiogenic shock?Heart Lung Circ201120S115

 Google Scholar

ZeymerUBauerTHammCUse and impact of intra-aortic balloon pump on mortality in patients with acute myocardial infarction complicated by cardiogenic shock: results of the Euro Heart Survey on PCIEuroIntervention20117443744121764661

 PubMed Web of Science ®Google Scholar

SjauwKDEngströmAEVisMMEfficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shockNeth Heart J2012201040240922847042

 PubMed Web of Science ®Google Scholar

ZeymerUHochadelMHauptmannKIntra-aortic balloon pump in patients with acute myocardial infarction complicated by cardiogenic shock: results of the ALKK-PCI registryClin Res Cardiol2013102322322723179136

 PubMed Web of Science ®Google Scholar

DziewierzASiudakZRakowskiTKleczyńskiPZasadaWDudekDImpact of intra-aortic balloon pump on long-term mortality of unselected patients with ST-segment elevation myocardial infarction complicated by cardiogenic shockPostepy Kardiol Interwencyjnej201410317518025489303

 PubMed Web of Science ®Google Scholar

OhmanEMCaliffRMGeorgeBSThe use of intraaortic balloon pumping as an adjunct to reperfusion therapy in acute myocardial infarction. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study GroupAm Heart J19911213 Pt 18959011900381

 PubMed Web of Science ®Google Scholar

MahmoudiMHauvilleCGagliaMAThe impact of intra-aortic balloon counter-pulsation on in-hospital mortality in patients presenting with anterior ST-elevation myocardial infarction without cardiogenic shockCardiovasc Revasc Med201213632833023062956

 PubMedGoogle Scholar

BrodieBRStuckeyTDHansenCMuncyDIntra-aortic balloon counterpulsation before primary percutaneous transluminal coronary angioplasty reduces catheterization laboratory events in high-risk patients with acute myocardial infarctionAm J Cardiol1999841182310404845

 PubMed Web of Science ®Google Scholar

KumbasarSDSemizESancaktarOYalçinkayaSErmişCDeğerNConcomitant use of intraaortic balloon counterpulsation and streptokinase in acute anterior myocardial infarctionAngiology199950646547110378822

 PubMed Web of Science ®Google Scholar

PereraDStablesRThomasMElective intra-aortic balloon counterpulsation during high-risk percutaneous coronary intervention: a randomized controlled trialJAMA2010304886787420736470

 PubMed Web of Science ®Google Scholar