In STEMI-related cardiogenic shock, escalation to temporary mechanical circulatory support was associated with a higher mortality risk of 71.7% compared to 48.1% in non-escalated patients.
Does initial treatment with a micro-axial flow pump compared to standard of care reduce the need for escalation to temporary mechanical circulatory support and impact 180-day mortality in non-comatose patients with STEMI-related cardiogenic shock?
In STEMI-related cardiogenic shock, initial use of a micro-axial flow pump reduces the likelihood of requiring escalation to higher-tier temporary mechanical circulatory support, an event associated with exceedingly high mortality.
Absolute Event Rate: 0% vs 0%
Abstract 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-p0.01). Mortality was significantly higher in patients who underwent tMCS escalation (71.7% vs. 48.1%, p0.01), 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.
Schrage et al. (Fri,) reported a other. In STEMI-related cardiogenic shock, escalation to temporary mechanical circulatory support was associated with a higher mortality risk of 71.7% compared to 48.1% in non-escalated patients.