The variability of genetic disease.

n engl j med 367;14 nejm.org october 4, 2012 1350 an adjusted multivariate model showed similar nonsignificant results. Finally, favorable trends with IABP were observed in younger patients and in those with a first myocardial infarction, although these findings can be considered only as hypothesis-generating. Given the concordance of data from the meta-analyses and the current trial, the data do not support the routine use of IABP in patients with acute myocardial infarction complicated by cardiogenic shock, and the level I guideline recommendation is now strongly challenged. Members of guideline committees and clinicians should take note of another example of a recommendation that is based on insufficient data. The results of the IABP-SHOCK II trial parallel those from many recent outcome trials that have challenged our understanding of the management of acute and chronic heart failure, including those regarding the use of pulmonary artery catheters9 and the role of revascularization in ischemic cardiomyopathy.10 Therapeutic strategies for patients with cardiogenic shock have changed abruptly and are ready for renewed growth and development. Although many will find the results of the IABPSHOCK II trial disappointing, we must recognize the opportunity to develop novel and innovative strategies to treat this condition. Integrated systems to ensure rapid reperfusion may reduce the incidence of shock among patients who have had an acute myocardial infarction.11 Secondary analyses of data from the IABP-SHOCK II trial may help us understand the mechanisms of the failed response. Comparing the patient populations and outcomes of the IABP-SHOCK II study groups and the concurrent registry cohort may yield important insights, with therapeutic implications for the use of other mechanical devices for circulatory support. On the basis of the findings of the IABP-SHOCK II trial, we must move forward with the understanding that a cardiovascular condition with 40% mortality at 30 days remains unacceptable. Most important, we hope that the results of this trial will galvanize a broadly based mandate to address this devastating clinical problem by reestablishing equipoise and international engagement in research on novel devices and pharmacologic therapies.