Early clinical recovery in STEMI cardiogenic shock: insights from the DanGer shock trial

The DanGer Shock trial demonstrated a mortality benefit with routine use of a microaxial flow pump (mAFP) in ST-elevation acute myocardial infarction complicated by cardiogenic shock (STEMI-CS), but at a cost of more complications. Routine use of a mAFP may, however, expose some patients to unnecessary risk, underscoring the need to identify those who stabilize rapidly and are less likely to derive benefit from device therapy.

This post hoc exploratory analysis of the DanGer Shock trial, which randomized STEMI-CS patients to mAFP plus standard care (SoC) or SoC alone, defined 'Fast Recovery' as cardiac intensive care unit (CICU) discharge alive within 3 days of randomization. Baseline variables available at catheterization lab admission associated with 'Fast Recovery' in the SoC arm were identified. Among 355 patients (SoC 176; mAFP 179), 'Fast Recovery' occurred in 29% of the SoC group vs. 15% of the mAFP group. Early CICU discharge favoured SoC through day 3 (HR 2.27, 95% CI 1.48-3.49), with no difference thereafter. Median CICU stay beyond day 3 was 13 days (SoC) vs. 12 days (mAFP), and 94 deaths occurred by day 3 (29% SoC; 24% mAFP). Compared with patients with longer CICU stays, 'Fast Recovery' patients required less inotropic support (44% vs. 85%) and mechanical ventilation (35% vs. 82%) and had lower 180-day mortality (9% vs. 46%, P < 0.001). In the SoC arm, 'Fast Recovery' was associated with lower age, initial higher LVEF, lower heart rate, and lower lactate. Model discrimination was modest (AUROC optimism-corrected 0.74).

The DanGer Shock trial showed a survival benefit of mAFP use in STEMI-CS, yet about one-third of SoC patients experienced rapid haemodynamic recovery. These 'Fast Recovery' patients were characterized by higher LVEF, younger age, and lower lactate, however discrimination between patients with and without rapid recovery was modest. Distinguishing patients who will recover rapidly remains challenging and warrants further investigation.