Intra-aortic balloon pump is associated with the lowest whereas Impella with the highest inpatient mortality and complications regardless of severity or hospital types (rural or university) or after adjustment for 47 high risk variables and baseline characteristics by studying over 800,000 inpatients with cardiogenic shock

Q: What are the key findings of this study?

In patients with cardiogenic shock, Impella utilization was associated with increased inpatient mortality (adjusted OR 1.33) while IABP was associated with decreased mortality (adjusted OR 0.69) compared to no device.

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Cardiogenic shock (n=844020). Intervention: Impella vs. No mechanical circulatory support. Primary outcome: Inpatient mortality (OR 1.33, 95% CI 1.25-1.41, p=<0.001).

Q: What does this research mean for the field?

In patients with cardiogenic shock, the use of an intra-aortic balloon pump (IABP) is associated with decreased in-hospital mortality, whereas the use of Impella is associated with increased in-hospital mortality, regardless of baseline comorbidities or hospital type. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Mohammad Reza Movahed; Armin Talle; Mehrtash Hashemzadeh

doi:10.1101/2024.01.17.24301446

January 18, 2024Open Access

Intra-aortic balloon pump is associated with the lowest whereas Impella with the highest inpatient mortality and complications regardless of severity or hospital types (rural or university) or after adjustment for 47 high risk variables and baseline characteristics by studying over 800,000 inpatients with cardiogenic shock

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Key result

Impella use in cardiogenic shock is linked to ~33% higher inpatient mortality compared to no device.

OR 1.33
95% CI 1.25-1.41
P<0.001
n=844,020

Why the study?

Impella and IABP are commonly utilized in cardiogenic shock, but their effect on mortality remains controversial.

Does the use of Impella or IABP improve in-hospital mortality in adult patients with cardiogenic shock compared to no mechanical circulatory support?

Study Design

Type

Observational (n=844,020)

Multicenter

Yes

Structured PICO

Does the use of Impella or IABP improve in-hospital mortality in adult patients with cardiogenic shock compared to no mechanical circulatory support?

P

Population

844,020 adult inpatients (age >18) with a diagnosis of cardiogenic shock.

I

Intervention

Mechanical circulatory support with Impella (n=39,645) or Intra-aortic balloon pump (IABP) (n=101,870).

C

Comparator

No mechanical circulatory support device.

O

Outcome

In-hospital mortality.hard clinical

Main Result

Effect estimate: OR 1.33 (95% CI 1.25-1.41)

Absolute Event Rate: 40.75% vs 34.22%

p-value: p=<0.001

In a large retrospective cohort of cardiogenic shock patients, IABP use was associated with reduced in-hospital mortality, whereas Impella use was associated with increased mortality and higher rates of severe bleeding and mechanical complications.

Limitations

Use of ICD-10 coding has inherent limitations in accurate diagnosis
Cannot exclude that patients who underwent Impella insertion were much sicker (unmeasured confounding)
Cannot assess how clinicians came to their decision on whether to use either an Impella, IABP, or no device in each patient
ICD-10 coding has inherent limitations in accurate diagnosis
Cannot assess how clinicians came to their decision on whether to use either an Impella, IABP, or no device

Implication

Caution advised with Impella in cardiogenic shock; observational data leaves open causal effects and optimal device selection pending RCTs.

Abstract

Background Impella and intra-aortic balloon pumps (IABP) are commonly utilized in patients with cardiogenic shock. However, the effect on mortality remains controversial. The goal of this study was to evaluate the effect of Impella and IABP on mortality and complications in patients with cardiogenic shock. Method The large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of IABP or Impella on mortality and complications in adults with a diagnosis of cardiogenic shocks. Results ICD-10 codes for Impella, IABP, and cardiogenic shock for available years 2016-2020 were utilized. A total of 844,020 patients had a diagnosis of cardiogenic shock. 101,870 were treated with IABP and 39,645 with an Impella. Total inpatient mortality without any device was 34.2% vs only 25.1% with IABP use (OR=0.65, CI 0.62-0.67) but was highest at 40.7% with Impella utilization (OR=1.32, CI 1.26-1.39). Using multivariate analysis adjusting for 47 variables such as age, gender, race, lactose acidosis, three-vessel intervention, left main myocardial infarction, cardiomyopathy, systolic heart failure, acute ST-elevation myocardial infarction, peripheral vascular disease, chronic renal disease, etc., Impella utilization remained associated with the highest mortality (OR: 1.33, CI 1.25-1.41, p<0.001) whereas IABP remained associated with the lowest mortality (OR: 0.69, CI 0.66-0.72, p<0.001). Separating rural vs teaching hospitals revealed similar findings. Conclusion In patients with cardiogenic shock, the use of Impella was associated with the highest whereas the utilization of IABP was associated with the lowest in hospital mortality regardless of comorbid condition, high-risk futures, or type of hospital.

Discussion

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Cite This Study

Movahed et al. (2024) conducted an observational in Cardiogenic shock (n=844,020). Impella vs. No mechanical circulatory support was evaluated on Inpatient mortality (OR 1.33, 95% CI 1.25-1.41, p=<0.001). In patients with cardiogenic shock, Impella utilization was associated with increased inpatient mortality (adjusted OR 1.33) while IABP was associated with decreased mortality (adjusted OR 0.69) compared to no device.

synapsesocial.com/papers/6a0edf5c950456576347d6a0 https://doi.org/10.1101/2024.01.17.24301446

Topics

Mechanical circulatory support

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Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Topics

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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