Randomized comparison of intraaortic balloon counterpulsation

versus optimal medical therapy in addition to early

revascularization in acute myocardial infarction complicated by cardiogenic shock

Holger Thiele, MDUwe Zeymer, MD; Franz-Josef Neumann, MD; Miroslaw Ferenc,

MD; Hans-Georg Olbrich, MD; Jörg Hausleiter, MD; Gert Richardt, MD; Marcus Hennersdorf, MD; Klaus Empen, MD; Georg Fuernau, MD; Steffen Desch, MD;

Ingo Eitel, MD; Rainer Hambrecht, MD; Jörg Fuhrmann, MD; Michael Böhm, MD; Henning Ebelt, MD; Steffen Schneider, PhD;

Gerhard Schuler, MD; Karl Werdan, MD

on behalf of the IABP-SHOCK II Trial Investigators

University of Leipzig – Heart Center

DisclosuresFunding:German Research FoundationGerman Heart Research Foundation German Cardiac SocietyArbeitsgemeinschaft Leitende Kardiologische Kranken hausärzteUniversity of Leipzig – Heart CenterUnrestricted grant by:Maquet Cardiopulmonary AG, Hirrlingen, Germany Teleflex Medical, Everett, MA, USA

Potential Conflict of Interest:Research Funding:Terumo, Lilly, Maquet Cardiovascular, Teleflex MedicalConsulting:Maquet Cardiovascular, LillySpeaker Honoraria:Lilly, Astra Zeneca, Daiichi Sankyo, Boehringer Ingelheim, Maquet Cardiovascular, Medicines Company

IABP in Cardiogenic Shock

History:

1962 Animal studiesMoulopoulos et al. Am Heart J 1962;63:669-675

1968 First clinical description in shockKantrowitz et al. JAMA 1968;203:135-140

1973 Hemodynamic effects in shock,Mortality unchangedScheidt et al. NEJM 1973;288:979-984

> 40 years > 1 Million patients treated, low complication rate , Benchmark registry Ferguson et al. JACC 2001;38:1456-1462

Background

Guidelines

IABP in AMI complicated by cardiogenic shock

Class IB

ACC/AHA

ESC

Class IC

Van de Werf et al. Eur Heart J 2008;29:2909-2945Wijns et al. Eur Heart J 2010;31:2501-2555Antman et al. Circulation 2004;110:82-292

Background

Sjauw et al. Eur Heart J 2009;30:459-468

-1 -0.5 0.5 10

No IABP betterIABP better

30-day mortalityRisk difference

IABPn/N

No IABPn/N

Trial

-0.29 (-0.47 to -0.12)

No reperfusion24/34

24/34

15/15

15/15

Moloupoulos

Overall

-0.11 (-0.13 to -0.09)Overall 2488/5146 3332/5283

-0.18 (-0.20 to -0.16)Overall

ThrombolysisStomel

Kovack

BengtsonWaksman

GUSTO-1

SHOCK registry

NRMI-2 TT

28/51

10/27

48/99

11/20

30/62

220/439

1068/2180

1415/2878

10/13

13/19

58/101

17/21

146/248

300/417

2346/3501

2890/4320

Overall 1049/2234 0.06 (0.03 to 0.10)

Primary PCINRMI-2 PCIAMC CS

956/2035

93/199

401/955

26/93

427/1048

Mortality IABP vs no IABP - MetaanalysisBackground

25 2531

3951

86

2211

22

0102030405060708090

ALKK

GUSTO IGUSTO II

I

Euro H

eart

Survey

Worce

ster-R

egist

ryNRM

I-2NRM

I 2-4

SHOCK-Reg

istry

SHOCK-Tria

l

IAB

P U

se(%

)

IABP-Use in Cardiogenic Shock

Thiele et al. Eur Heart J 2010,31:1828-1835

Background

Study Sites and Organisation

DSMB:Kurt HuberFerenc FollathBernhard MaischJohannes HaertingSteering committee:Holger ThieleKarl WerdanUwe ZeymerGerhard SchulerSupport + Patronage:

Methods

IABP-Shock -II Trial –– TimelinesTimelines

Milestone 32. Interim-

analysis

Milestone 4Last patient

Year 1 Year 2 Year 3 Year 4 Year 5

Patient recruitment

Follow-up

Preparation (Study proto-

col, IRB, etc.)

1 1 44 7 7 1010 1 4 7 10 1 4 7 10 1 4

Milestone 5Final Analysis

Primary Endpoint

Database cleaning

Statistics

Milestone 6Final Analysis

Follow-up

Database cleaning

Statistics

Milestone 21. Interim-analysis

Milestone 11. Patient

Initiation

600/600 Patients03/2012

Methods

1/600 Patients06/2009

Statistical MethodologySample Size

– Estimated 12% absolute difference in survival rates– Sequential statistical design with 2 interim analys es (33% and 66% of patients)– Significance level 0.0005 at 1st or 0.014 at 2nd in terim analysis.

Final analysis at α-level 0.044 → 564 patients– To compensate losses in follow-up and putative cent er effect → 600 patients

Thiele et al. Am Heart J 2012;163:938-45

Methods

Primary Study Endpoint :30-day all-cause mortality

Secondary Study Endpoints:- Hemodynamic parameters (mean BP, heart rate pre and post revascularization)- Serum-lactate (every 8 h for 48 h)- SAPS-2 Score- Serial creatinine-level and creatinine-clearance (C ockcroft-Gault-formula)- Inflammatory reaction (CRP)Process of care- Time until hemodynamic stabilization- Catecholamine dose and duration- Requirement for LVAD-implantation or HTx- Requirement for renal replacement therapy- Length of ICU-stay- Length of mechanical ventilation- Mortality after 6 and 12 months

298 primary endpoint analysis

600 randomized

299 randomized to control• 269 received control therapy• 30 cross-over to IABP (22 first day, 8 day 1-8)

- 4 mechanical complications- 25 protocol violation- 1 unknown reason

Allocation

300 with 30-day follow-up- 1 lost to follow-up

298 with 30-day follow-up- 1 withdrew informed consent

Follow-up

300 primary endpoint analysis

Primary endpointanalysis

790 patients with AMI and cardiogenic shock screene d

299 intended early revascularization• 288 primary PCI• 3 primary CABG• 8 no revascularization

- 1 not suitable for revascularization- 2 coronary artery disease with no identifiable culprit lesion- 5 no coronary artery disease

Revascularization

190 excluded because of exclusion criteria- 60 no informed consent- 47 resuscitation >30 minutes- 19 shock duration >12 hours- 18 severe peripheral artery disease- 14 participation in another trial- 13 no intrinsic heart activity- 9 mechanical complication- 3 shock of other cause- 3 comorbidity with life expectancy <6 months- 2 severe cerebral deficit- 2 age >90 years

Results Trial Flow and Treatment

301 randomized to IABP• 288 received IABP• 13 did not receive IABP

- 10 died before IABP insertion- 3 protocol violation

(2 not suitable for revascularization, 1 serious kinking)

301 intended early revascularization• 287 primary PCI• 3 primary CABG• 11 no revascularization

- 3 not suitable for revascularization - 4 coronary artery disease with no identifiable culprit lesion- 4 no coronary artery disease

Patient CharacteristicsResults

121/293 (41.3)57/293 (19.5)79/293 (27.0)28/293 (9.6)8/293 (2.7)

132/293 (45.1)55/293 (18.8)73/293 (24.9)26/293 (8.9)7/293 (2.4)

Infarct related artery; n/total (%)LADLCXRCALeft mainBypass graft

56.8 (39.7-78.1)60.7 (43.4-86.6)Creatinine clearance (ml/min); median (IQR)

20/299 (6.7)28/301 (9.3)Fibrinolysis < 24 h before randomization; n/total ( %)

35 (25-45)35 (25-45)Left ventricular ejection fraction (%); median (IQR )

228/293 (77.9)235/296 (79.4)Multivessel disease; n/total (%)

232/299 (77.6)245/299 (81.9)99/299 (33.1)218/298 (73.2)

215/300 (71.7)257/300 (85.7)90/300 (30.0)226/300 (75.3)

Signs of impaired organ perfusion; n/total (%)Altered mental statusCold, clammy skin and extremitiesOliguriaSerum lactate >2.0 mmol/l

143/299 (47.8)127/301 (42.2%)Resuscitation before randomization; n/total (%)

212/298 (71.1)81/298 (27.2)

200/300 (66.7)96/300 (32.0)

STEMI/LBBB; n/total (%)NSTEMI; n/total (%)

12/299 (4.0)20/300 (6.7)Prior CABG; n/total (%)

52/299 (17.4)63/299 (21.1)Prior PCI; n/total n (%)

61/299 (20.4)71/300 (23.7)Prior myocardial infarction; n/total n (%)

26.9 (24.7-29.4)27.5 (24.7-30.1)Body mass index (kg/m 2); median (IQR)

108/299 (36.1)199/299 (66.6)105/299 (35.1)90/299 (30.1)

96/295 (32.5)213/296 (72.0)122/295 (41.4)105/297 (35.4)

Current Smoking; n/total (%)Hypertension; n/total (%)Hypercholesterolemia; n/total (%)Diabetes mellitus; n/total (%)

211 (70.6)202 (67.1)Male sex; n (%)

69 (58-76)70 (58-78)Age (years); median (IQR)

Control (n=299)IABP (n=301)

Treatment + Process of Care OutcomesResults

0.503.0 (1.0-6.0)3.0 (1.0-5.0)Time to hemodynamic stabilization (days); median (IQR)

0.813.0 (1.0-6.0)3.0 (1.0-5.0)Duration of catecholamines (days), median (IQR)

0.760.730.590.25

4.2 (3.6-8.3)0.4 (0.1-1.1)0.3 (0.2-1.4)9.0 (4.8-17.6)

4.1 (2.9-7.7) 0.3 (0.1-1.2)0.3 (0.1-1.3)

10.2 (4.9-20.6)

Catecholamines (μg/kg per minute); median (IQR)DopamineNorepinephrineEpinephrineDobutamine

0.070.400.730.520.63 0.030.940.34

284/298 (95.3)206/298 (69.1)76/298 (25.5)15/228 (6.6)

143/298 (48.0)275/298 (92.3)59/298 (19.8)36/298 (12.1)

293/299 (98.0)216/299 (72.2)80/299 (26.8)19/234 (8.1)

138/299 (46.2)288/299 (96.3)60/299 (20.1)29/299 (9.7)

Antiplatelets and anticoagulation; n/total (%)AspirinClopidogrelPrasugrelTicagrelor*Glycoprotein IIb/IIIa-inhibitorsUnfractionated heparinLow molecular weight heparinBivalirudin

0.1247/299 (15.7)62/301 (20.6)Renal replacement therapy; n/total (%)

0.346.0 (3.0-13.0)6.0 (3.0-12.0)Duration of intensive care treatment (days); median (IQR)

0.443.0 (1.0-8.0)3.0 (1.0-8.0)Duration of mechanical ventilation (days); median (IQR)

0.15252/299 (84.3)240/301 (79.7)Mechanical ventilation; n/total (%)

0.21120/299 (40.1)106/301 (35.2)Mild hypothermia; n/total (%)

0.05322/299 (7.4)11/301 (3.7)Active left ventricular assist device; n/total (%)

0.724/299 (1.3)3/301 (1.0)Staged bypass surgery; n/total (%)

0.6210/299 (3.3)8/301 (2.7)Immediate bypass surgery; n/total (%)

0.4581/299 (27.1)90/301 (29.9)Immediate PCI of non-culprit lesions; n/total (%)

0.86123/299 (41.1)126/301 (41.9)Drug-eluting stent; n/total (%)

0.48266/299 (89.0)273/301 (90.7)Stent implanted; n/total (%)

0.55288/299 (96.3)287/301 (95.3)Primary PCI; n/total (%)

pControl (n=299)IABP (n=301)Variable

0

10

20

30

40

50

60

70

80

P=0.34 P=0.14P=0.005P=0.02P=0.89

Sim

plifi

ed A

cute

Phy

siol

ogy

Sco

re-I

I

Baseline Day 1 Day 2 Day 3 Day 4

Simplified Acute Physiology Score-IIResults

ControlIABP

0

10

20

30

40

50

60

70

80

90

100 P=0.55 P=0.34P=0.55P=0.96P=0.12

Baseline Day 1 Day 2 Day 3 Day 4

Est

imat

ed G

lom

erul

ar F

iltra

tion

Rat

e (m

l/min

)

Results Renal Function (eGFR)

ControlIABP

0

1

2

3

4

5

6

7

8

9

P=0.43

P=0.12

P=0.06

P=0.32P=0.32 P=0.37

Baseline 8 hours 16 hours 24 hours 32 hours 40 hours 48 hours

Ser

um L

acta

te (

mm

ol/l)

P=0.09

ControlIABP

Results Serum Lactate

0

50

100

150

200

250

300

P=0.39

P=0.55

P=0.85

P=0.56

P=0.01C-R

eact

ive

Pro

tein

(m

g/l)

Baseline Day 1 Day 2 Day 3 Day 4

Results Inflammatory Reaction (CRP)

ControlIABP

Mor

talit

y (%

)

Time after Randomization (Days)

P=0.92 by log-rank testRelative risk 0.96; 95% CI 0.79-1.17; P=0.69 by Chi2-Test

Primary Study Endpoint (30-Day Mortality)Results

Control41.3%

IABP 39.7%

0

10

20

30

40

50

0 5 10 15 20 25 30

0 0.5 1 1.5 2 2.5IABP better Control better

Results Subgroups (30-Day Mortality)

187411

Baseline Variable N30-Day Mortality (%)

IABP ControlRelative Risk

(95% CI)P-Value forInteraction

FemaleMale

Age <50 yearsAge 50-75 yearsAge >75 years

DiabetesNo diabetes

HypertensionNo hypertension

STEMI/LBBBNSTEMI

Anterior STEMI Non-anterior STEMI

Previous infarctionNo previous infarction

HypothermiaNo hypothermia

70334194

195399

410183

412177

216196

131466

226372

44.437.3

19.434.653.7

42.937.2

42.928.9

41.037.5

35.448.3

47.937.3

48.135.1

43.240.5

44.136.540.0

46.738.9

40.443.0

42.938.3

43.742.2

33.343.3

44.239.3

1.03 (0.74-1.43)0.92 (0.72-1.18)

0.44 (0.21-0.95)0.95 (0.71-1.27)1.07 (0.81-1.41)

0.92 (0.67-1.26)0.96 (0.74-1.23)

1.06 (0.84-1.34)0.67 (0.45-1.01)

0.96 (0.77-1.21)0.98 (0.67-1.43)

0.81 (0.58-1.13)1.16 (0.85-1.57)

1.44 (0.93-2.21)0.86 (0.69-1.07)

1.09 (0.82-1.44)0.89 (0.68-1.16)

0.61

0.09

0.82

0.05

0.76

0.14

0.04

0.31

Blood pressure <80 mmHgBlood pressure ≥80 mmHg

161432

50.735.9

46.439.2

1.09 (0.79-1.50)0.92 (0.72-1.17)

0.76

Safety

IABP (n=300) Control (n=298) P

Stroke in-hospital n/total (%) 2/300 (0.7) 5/298 (1.7) 0.28

GUSTO bleeding; n/total n (%)

Life-threatening/severeModerate

10/300 (3.3) 52/300 (17.3)

13/298 (4.4) 49/298 (16.4)

0.51 0.77

Peripheral ischemic complication requiring intervention; n/total n (%) 13/300 (4.3) 10/298 (3.4) 0.53

Sepsis; n/total n (%) 47/300 (15.7) 61/298 (20.5) 0.15

Results

Trial n/N n/NRelative Risk

95% CIRelative Risk95% CI

0 0.5 1 2 3

Randomized Studies in Cardiogenic ShockFollow-up

Revascularization (PCI/CABG)SHOCKSMASHTotal

76/15222/32

103/184

83/14918/23

117/172

0.80 (0.66;0.98)0.87 (0.66;1.29)0.82 (0.70;0.98)

1-year30 days

Early revascularization better

Medical treatmentbetter

0.75 1.5 2.50.25

Norepinephrinebetter

0.75 (0.55;0.93)64/145 50/13528 daysDopamine better

CatecholaminesSOAP II (CS Subgroup)

In-hospital 15/40 13/40 1.15 (0.59;2.27)Up-stream Abciximabbetter

Standard treatmentbetter

Glycoprotein IIb/IIIa-InhibitorsPRAGUE-7

97/20124/59

4/15125/275

30 days30 days30 days

76/1807/20

10/1593/215

1.14 (0.91;1.45)1.16 (0.59;2.69)0.40 (0.13;1.05)1.05 (0.85;1.29)

NO Synthase inhibitionbetter

Placebobetter

NO Synthase InhibitorsTRIUMPHSHOCK-2Cotter et alTotal

30 days30 days30 days

9/219/196/13

24/53

9/205/146/13

20/47

0.95 (0.48;1.90)1.33 (0.57-3.10)1.00 (0.44-2.29)1.06 (0.68-1.66)

LVADbetter

IABPbetter

LVADThiele et alBurkhoff et alSeyfarth et alTotal

Updated from Thiele et al. Eur Heart J 2010,31:1828-1835

30 days30 days

7/19119/300126/319

6/21123/298129/319

IABPbetter

Standard treatmentbetter

1.28 (0.45;3.72)0.96 (0.79;1.17)0.98 (0.81;1.18)

IABPIABP-SHOCK IIABP-SHOCK IITotal

Summary + Conclusions

• IABP support in cardiogenic shock is safe without significant inherent complications.

• However, IABP support did not reduce 30-day mortality in this large, randomized, multicenter trial in cardiogenic shock patients complicating myocardial infarction undergoing early revascularization.

• The primary study endpoint results are supported by a lack of benefit in secondary endpoints.

Acknowledgement and Thank You

H. Thiele (Chair)G. SchulerK. WerdanU. Zeymer

J. Haerting (Chair)F. FollathK. HuberB. Maisch

DFGDSHFDGKALKKUniversity of Leipzig –Heart CenterMaquet CardiovascularTeleflex Medical

H. ThieleU. Zeymer

Steering Committee

DSMB

CEC

Funding

IABP-SHOCK II Investigators from 37 German Sites

S. Schneider (Statistics chair)T. Oarrak (Statistics)U. ZeymerK. VonderschmittZ. AlkisogluS. FreyB. Messemer

CRO IHF Ludwigshafen

Leipzig; H. Thiele, G. Schuler, S. Desch, G. Fuernau, I. Eitel, S. de Waha, S. Wetzel, T. Pausewang, A. LeuschnerBad Krozingen: F.-J. Neumann, M. FerencLangen. H.-G. Olbrich, H.-B. HopfMunich German Heart Center: J. Hausleiter, A. de Waha, M. Orban, C. Lennerz, M. SeyfarthBad Segeberg: G. Richardt, B. Schwarz, M. Abdel-Wahab, R. Toelg, V. Geist, M. Bahnsen-MaaßHeilbronn: M. Hennersdorf, U. Rieman, J. Graf, A. Kuhn, D. ScharpfGreifswald: K. Empen. S. FelixHalle (Saale): K. Werdan, H. Ebelt, A. Schlitt, M. BuerkeBremen: R. Hambrecht, E. Fiehn, A. FachLudwigshafen: U. .Zeymer, A. K. Gitt, B. Mark, R.WinklerBad Berka: B. Lauer, J. FuhrmannHomburg/Saar: M. Böhm, A. LinkJena: H.R. Figulla, M. Ferrari, C. Jung, S. UtschigLübeck: V. Kurowski, S. Wolfrum, P.W. Radke, H. SchunkertHennigsdorf: H.-H. MindenMagdeburg: R. C. Braun-Dullaeus, F. Walz, A. SchmeißerCottbus – Heart Center: J. Krülls-Münch, K. RochorDresden: R. H. Strasser, G. SimonisWürzburg: S. Maier, G. ErtlMunich – Neuperlach: H. Mudra, M. HugRegensburg: P. Bomba, P. SickBerlin – Banjamin Franklin: C. Tschöpe, H.-P. SchutlheissBerlin – Vivantes am Urban: H. Roth, D. AndresenCottbus – Carl-Thiem-Klinikum: C. Kurek, J. Krülls-MünchRostock: C. Nienaber, H. Ince, H. SchneiderBad Nauheim: C. Hamm, H. MöllmannErfurt: H. LappBerlin – Charité Mitte: G. Baumann, F. KnebelMunich – Großhadern: W. FranzBerlin – Vivantes AVK: H. Schühlen, L. U. SttrackeWeiden: R. H. Schwinger, H. BäumlFulda: V. SchächingerEssen: M. LichtenbergUnna: D. GießmannMerseburg: R. ProndzinskyDetmold: U. TebbeVillingen-Schwenningen: R. Birkemeyer

Study Sites