Skip to main content

Escalation of Mechanical Circulatory Support in Patients with STEMI-related Cardiogenic Shock: A post-hoc Analysis of the DanGer Shock Trial.

European heart journal. Acute cardiovascular care

Authors: Benedikt Schrage, Rasmus Paulin Beske, Christian Hassager, Lisette Okkels Jensen, Hans Eiskjær, Norman Mangner, Amin Polzin, P Christian Schulze, Carsten Skurk, Peter Nordbeck, Vasileios Panoulas, Sebastian Zimmer, Andreas Schäfer, Nikos Werner, Thomas Engstrøm, Lene Holmvang, Nanna Louise Junker Udesen, Henrik Schmidt, Anders Junker, Christian Juhl Terkelsen, Steffen Christensen, Axel Linke, Dirk Westermann, Peter Clemmesen, Jacob Eifer Møller

BACKGROUND: In STEMI-related cardiogenic shock, left ventricular unloading with a micro-axial flow pump (mAFP) improved survival in the Danish German (DanGer) Shock trial, though some patients in both groups required escalation to higher volume temporary mechanical circulatory support systems (tMCS).

OBJECTIVES: To investigate tMCS escalation strategies and outcome in non-comatose patients with STEMI-related cardiogenic shock.

METHODS: In this post-hoc analysis of the DanGer Shock trial, patients in both study groups were stratified as escalated vs. not escalated to treatments other than a percutaneously implanted mAFP (Impella CP®). Logistic regression models were fitted to investigate the differential association of baseline markers with the likelihood of an escalation in patients randomized to mAFP vs. standard of care, adjusted for age and country. 180-day all-cause mortality risk for the four groups was evaluated using the Kaplan-Meier method.

RESULTS: Of 355 patients included in the DanGer Shock trial, 60 underwent tMCS escalation, 25/179 (14%) allocated to the mAFP group and 35/176 (20%) allocated to the control group (adjusted odds ratio 0.52, 95% confidence interval 0.30-0.91). Median time from randomization to escalation was 12 hours (2.7 to 66.5) in the mAFP arm vs. 0.7 hours (IQR: 0.4-2.7) in the standard of care arm, P < 0.001). A higher baseline lactate predicted an escalation in the standard of care arm (odds ratio 1.80, 95% confidence interval 1.14-3.13), but not in the mAFP arm (odds ratio 0.57, 95% confidence interval 0.29-1.15, interaction-p<0.01). Mortality was significantly higher in patients who underwent tMCS escalation (71.7% vs. 48.1%, p<0.01), and highest in escalated patients from the standard of care arm (80.0%). Interestingly, those escalated in the mAFP arm had a comparable mortality risk to the non-escalated patients in the standard of care group (60.0% vs. 53.2%).

CONCLUSIONS: In the DanGer Shock trial of STEMI-related cardiogenic shock, escalation to tMCS occurred in almost 1/5 patients, was more likely in the control group, and was associated with a higher mortality risk. Even with early escalation (<1 hour), patients escalated from the control group had the highest mortality, underscoring the need for future trials to define optimal escalation strategies.

© The Author(s) 2026. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.

PMID: 41607344

Participating cluster members