Antithrombotic strategies and outcomes in acute myocardial infarction-related cardiogenic shock requiring short-term mechanical circulatory support

Background Cardiogenic shock following acute myocardial infarction (AMI-CS) is associated with high mortality. Short-term mechanical circulatory support (ST-MCS) is frequently used after percutaneous coronary intervention (PCI) to stabilize hemodynamics. However, balancing anticoagulation (AC) and antiplatelet therapy in this setting poses substantial bleeding risk. Objectives This study aimed to evaluate real-world antithrombotic strategies and associated ischemic and hemorrhagic complications in AMI-CS patients receiving ST-MCS. Methods This retrospective, single-center study included all consecutive AMI-CS patients who underwent PCI and required ST-MCS between January 2017 and October 2024. AC and antiplatelet regimens were recorded from ST-MCS initiation until shock resolution. Ischemic and hemorrhagic events during this period were analyzed. The primary composite clinical endpoint was major adverse cardiovascular events (MACE), defined as a composite of ischemic events and all-cause mortality occurring during the period of cardiogenic shock. Results Among 71 patients with AMI-CS who underwent PCI and required ST-MCS (mean age 62 ± 13 years, 69% male), in-hospital mortality was 56%, and MACE occurred in 42%. At ST-MCS initiation, 79% received triple therapy, decreasing to 39% by Day 7. Ischemic events were infrequent (8%) and mainly cerebrovascular. No cases of recurrent myocardial infarction or stent thrombosis were observed. Major bleeding (BARC ≥ 3) occurred in 32% of patients, typically within the first 48 h, and was more frequent in those supported with VA-ECMO. Conclusion In AMI-CS patients requiring ST-MCS, ischemic events were uncommon, whereas major bleeding was frequent and occurred early. These findings underscore the need for individualized antithrombotic strategies in this high-risk population.