Pitfalls in the World of Evidence-Based Medicine: Should IABP Be en-DANGER-ed by the DanGer Shock Trial?

A 67-year-old male with no past medical history presented with indigestion and dizziness to a hospital in a town in the state of Georgia in 2018 was hypotensive, and his ECG showed STEMI (ST-segment–elevation myocardial infarction). Cardiac catheterization revealed severe proximal stenosis in the left anterior descending artery. While attempting to wire the lesion, he deteriorated rapidly from underlying cardiogenic shock (CS) and succumbed to pulseless electrical activity arrest. No temporary mechanical support device (t-MCSD) was used, with the interventional cardiologist reasoning being: “There is no data to support that intra-aortic balloon pumps (IABP) work in STEMI-CS, and we did not have any other devices available.” The patient was one of the author’s (A.B.) uncles.

Trial results in CS have been contradictory to clinical practice experience and subject to interpretation, especially in relation to utilization of t-MCSD. Often, clinicians get polarized into believers and nonbelievers when it comes to a choice of t-MCSD. A similar divide occurs in the use of pulmonary artery catheters in CS (currently being investigated in the PACCS trial [Pulmonary Artery Catheter in Cardiogenic Shock]: NCT05485376). An extreme stance on futility against a t-MCSD (in the absence of availability of an alternative therapy) as shown in the case above reflects on many challenges that clinical decision-making in CS faces. We present here our perspective to highlight: (1) limitations of existing clinical trials that evaluated IABP in CS and (2) misinterpretation of the trials that has led to inappropriate application of existing data. We hope to create awareness in the field of CS to avoid unintended consequences for individual patients.