International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
JAMA Intern Med. 2015 Jun;175(6):931-939. doi: 10.1001/jamainternmed.2015.0569.
Intra-aortic balloon pump (IABP) therapy is a widely used intervention for acute myocardial infarction with cardiogenic shock. Guidelines, which previously strongly recommended it, have recently undergone substantial change.
To assess IABP efficacy in acute myocardial infarction.
Human studies found in Pubmed, Embase, and Cochrane libraries through December 2014 and in reference lists of selected articles. Search strings were "myocardial infarction" or "acute coronary syndrome" and "intra-aortic balloon pump" or "counterpulsation."
Randomized clinical trials (RCTs) and observational studies comparing use of IABP with no IABP in patients with acute myocardial infarction.
Two reviewers independently extracted the data, and risk of bias in RCTs was assessed using the Cochrane risk of bias tool. We conducted separate meta-analyses of the RCTs and observational studies. Data were quantitatively synthesized using random-effects meta-analysis.
Thirty-day mortality.
There were 12 eligible RCTs randomizing 2123 patients. In the RCTs, IABP use had no statistically significant effect on mortality (odds ratio [OR], 0.96 [95% CI, 0.74-1.24]), with no significant heterogeneity among trials (I2 = 0%; P = .52). This result was consistent when studies were stratified by the presence (OR, 0.94 [95% CI, 0.69-1.28]; P = .69, I2 = 0%) or absence (OR, 0.98 [95% CI, 0.57-1.69]; P = .95, I2 = 17%) of cardiogenic shock. There were 15 eligible observational studies totaling 15 530 patients. Their results were mutually conflicting (heterogeneity I2 = 97%; P < .001), causing wide uncertainty in the summary estimate for the association with mortality (OR, 0.96 [95% CI, 0.54-1.70]). A simple index of baseline risk marker imbalance in the observational studies appeared to explain much of the heterogeneity in the observational data (R2meta = 46.2%; P < .001).
Use of IABP was not found to improve mortality among patients with acute myocardial infarction in the RCTs, regardless of whether patients had cardiogenic shock. The observational studies showed a variety of mutually contradictory associations between IABP therapy and mortality, much of which was explained by the differences between studies in the balance of risk factors between IABP and non-IABP groups.
主动脉内球囊泵（IABP）治疗是急性心肌梗死合并心源性休克的一种广泛应用的干预手段。先前强烈推荐使用的指南最近发生了重大变化。
评估 IABP 在急性心肌梗死中的疗效。
通过 Pubmed、Embase 和 Cochrane 图书馆在 2014 年 12 月前检索到的人类研究，并在选定文章的参考文献中检索到。搜索字符串为“心肌梗死”或“急性冠状动脉综合征”和“主动脉内球囊泵”或“反搏”。
比较急性心肌梗死患者使用 IABP 和不使用 IABP 的随机临床试验（RCT）和观察性研究。
两名审查员独立提取数据，使用 Cochrane 偏倚风险工具评估 RCT 的偏倚风险。我们对 RCT 和观察性研究分别进行了荟萃分析。使用随机效应荟萃分析对数据进行定量综合。
30 天死亡率。
共有 12 项符合条件的 RCT 纳入了 2123 名患者。在 RCT 中，IABP 的使用对死亡率没有统计学上的显著影响（优势比 [OR]，0.96 [95%CI，0.74-1.24]），试验之间没有显著的异质性（I2=0%；P=0.52）。当根据是否存在（OR，0.94 [95%CI，0.69-1.28]；P=0.69，I2=0%）或不存在（OR，0.98 [95%CI，0.57-1.69]；P=0.95，I2=17%）心源性休克对研究进行分层时，结果是一致的。共有 15 项符合条件的观察性研究共纳入 15530 名患者。它们的结果相互矛盾（异质性 I2=97%；P<0.001），导致死亡率关联的汇总估计值存在广泛的不确定性（OR，0.96 [95%CI，0.54-1.70]）。观察性研究中基线风险标志物不平衡的简单指标似乎解释了观察性数据中大部分的异质性（R2meta=46.2%；P<0.001）。
在 RCT 中，IABP 的使用并未发现可改善急性心肌梗死患者的死亡率，无论患者是否有心源性休克。观察性研究显示 IABP 治疗与死亡率之间存在各种相互矛盾的关联，其中大部分可以通过 IABP 和非 IABP 组之间的危险因素平衡差异来解释。
