Multimodality Cardiac Imaging Substudy of the DAPT-SHOCK-AMI Randomized Trial: Echocardiographic and Cardiac Magnetic Resonance Assessment of Cangrelor versus Crushed Ticagrelor in Cardiogenic Shock Complicating Acute Myocardial Infarction
IV cangrelor cuts microvascular obstruction odds ~73% vs crushed ticagrelor in AMI cardiogenic shock.
OR 0.27
95% CI 0.08-0.98
P=0.023
n=220
Key points
Context & question:In acute myocardial infarction complicated by cardiogenic shock, the myocardium suffers from both culprit-territory ischemia and global hypoperfusion. The DAPT-SHOCK-AMI Imaging substudy used serial multimodality imaging to examine the previously uninvestigated question of how and over what time course platelet inhibition at reperfusion (intravenous cangrelor versus crushed ticagrelor) affects the microcirculation, infarcted and noninfarcted myocardium, and ventricular functi.
Methods & population:Study design, patient population, and sample size are not yet reported.
Finding & limits:Intravenous cangrelor significantly reduced the primary imaging endpoint of acute microvascular obstruction on cardiac magnetic resonance compared with crushed oral ticagrelor (adjusted OR 0.27, 95% CI 0.08–0.98; P=0.023).
Discussion
Expert perspectives 2
Author’s perspective
Zuzana MotovskaCharles University and University Hospital Kralovske Vinohrady
“Achieving early and effective platelet inhibition is vital for reperfusion at the microcirculatory level in patients with MI complicated with cardiogenic shock. However, major randomised trials on the efficacy and safety of antiplatelet drugs have not included patients with cardiogenic shock. Currently, oral crushed ticagrelor tablets are given; however, the parenteral, direct-acting, reversible P2Y12 inhibitor, cangrelor, may address issues that occur during cardiogenic shock, including poor absorption and impaired liver metabolism.”
Beyond the findings regarding cangrelor, this trial establishes the value of serial echocardiography and MRI in characterizing recovery
DAPT-SHOCK-AMI Imaging co-author
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Full evidence
Why the trial, key points, tables, limitations, PICO, abstract, media & sources
Why the trial?
In acute myocardial infarction complicated by cardiogenic shock, the myocardium suffers from both culprit-territory ischemia and global hypoperfusion. The DAPT-SHOCK-AMI Imaging substudy used serial multimodality imaging to examine the previously uninvestigated question of how and over what time course platelet inhibition at reperfusion (intravenous cangrelor versus crushed ticagrelor) affects the microcirculation, infarcted and noninfarcted myocardium, and ventricular functi
Does intravenous cangrelor reduce acute microvascular obstruction and improve myocardial tissue characteristics and ventricular function compared with crushed oral ticagrelor in patients with acute myocardial infarction complicated by cardiogenic shock?
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Key Points
Determine whether immediate platelet inhibition with intravenous cangrelor compared with crushed oral ticagrelor alters microvascular obstruction, myocardial tissue injury, and functional recovery in acute myocardial infarction complicated by cardiogenic shock.
Prespecified multimodality imaging substudy of the randomized DAPT-SHOCK-AMI trial conducted at designated imaging sites comparing intravenous cangrelor with crushed oral ticagrelor.
Patients underwent serial echocardiography (208 enrolled; evaluable in 175 acutely, 120 at 1 month, and 99 at 1 year) and cardiac magnetic resonance (93 enrolled; evaluable in 73 acutely, 68 at 1 month, and 63 at 1 year), evaluated by blinded core laboratories.
The primary imaging endpoint was microvascular obstruction on acute CMR (n=60); secondary endpoints included infarct size, remote myocardial native T1, and left ventricular function over 1 year analyzed with covariate-adjusted models.
The odds of acute microvascular obstruction were significantly lower with cangrelor than with crushed ticagrelor (adjusted OR 0.27 [95% CI 0.08 to 0.98]; P=0.023), with no difference in infarct size.
At 1 year, native T1 of the remote myocardium was significantly lower in the cangrelor group (adjusted mean 1114 ms [95% CI 1057 to 1171] vs 1171 ms [95% CI 1115 to 1228]; P=0.005).
Left ventricular ejection fraction improved significantly more at 1 year with cangrelor on echocardiography (37.9% vs 21.7% relative increase; adjusted P=0.046) and CMR (15.8% vs 2.1%; P=0.027), along with better strain and lower filling pressures, whereas no differences occurred at 1 month.
Structured PICO
Does intravenous cangrelor reduce acute microvascular obstruction and improve myocardial tissue characteristics and ventricular function compared with crushed oral ticagrelor in patients with acute myocardial infarction complicated by cardiogenic shock?
PPopulation
220 patients with acute myocardial infarction complicated by cardiogenic shock enrolled at prespecified imaging sites (208 underwent echocardiography, 93 underwent CMR, 81 underwent both) and followed for up to 1 year.
IIntervention
Intravenous cangrelor at reperfusion
CComparator
Crushed oral ticagrelor at reperfusion
OOutcome
Microvascular obstruction (MVO) on acute cardiac magnetic resonance (CMR), analyzed by blinded core laboratories (evaluable in 60 patients)surrogate endpoint
Main Result
Odds Ratio0.27 (95% CI 0.08–0.98)
p-valuep=0.023
In patients with AMI complicated by cardiogenic shock, intravenous cangrelor was associated with less acute microvascular obstruction, lower 1-year remote myocardial native T1, and greater 1-year LVEF recovery compared with crushed oral ticagrelor, despite no difference in infarct size.
Limitations
The substudy was not separately powered
Findings are hypothesis-generating and do not establish a treatment mechanism
Primary imaging endpoint was evaluable in 60 patients
Attrition in evaluable imaging studies over 1 year (acute MVO evaluable in 60 patients)
Expert reaction
What experts said about DAPT-SHOCK-AMI Imaging
Circulation · AHA Scientific Sessions 2026
Cardiac imaging evidence still forming
1 expert has reacted so far. We show the split once 3 have.
“Larger trials are needed to confirm the findings related to numerically lower CV mortality at one year, which if verified, could represent a major advancement in the treatment of cardiogenic shock.”
Expert labels are toward DAPT-SHOCK-AMI Imaging's result, from named public quotes (n=1). As of Nov 8, 2026.
Implication
Cangrelor reduces acute MVO versus ticagrelor in AMI with shock; extends randomized evidence for microvascular protection and supports larger outcome trials.
Abstract
Background: In acute myocardial infarction complicated by cardiogenic shock (AMI-CS), the myocardium sustains a dual injury: ischemia of the culprit territory and global hypoperfusion from low cardiac output. Whether platelet inhibition at reperfusion affects the microcirculation, the infarct, the noninfarcted myocardium, and ventricular function, and over what time course, has not been examined with serial imaging. The prespecified multimodality imaging substudy of the randomized DAPT-SHOCK-AMI trial (intravenous cangrelor versus crushed oral ticagrelor) addressed this question.
Methods: Patients at prespecified imaging sites underwent serial echocardiography (208 enrolled; evaluable examinations in 175, 120, and 99 patients in the acute phase, at 1 month, and at 1 year) and cardiac magnetic resonance (CMR; 93 enrolled; 73, 68, and 63); 81 patients (40 and 41) underwent both modalities. Blinded core laboratories analyzed all studies. The primary imaging endpoint was microvascular obstruction (MVO) on acute CMR, evaluable in 60 patients; secondary endpoints were infarct size, native T1 of the global, infarcted, and remote myocardium, left ventricular (LV) ejection fraction (LVEF), global longitudinal strain (GLS), E/e', and left atrial volume, and their changes. Comparisons between the cangrelor and crushed ticagrelor arms used covariate-adjusted logistic or linear regression; the substudy was not separately powered.
Results: The odds of acute MVO were lower with cangrelor (adjusted odds ratio 0.27 [95% CI 0.08 to 0.98]; P=0.023). Infarct size did not differ between the arms. At 1 year, native T1 of the remote myocardium was lower with cangrelor (adjusted mean 1114 [95% CI 1057 to 1171] versus 1171 [1115 to 1228] ms; P=0.005). Over 1 year, LVEF increased more with cangrelor on echocardiography (37.9% versus 21.7% of the acute value; adjusted P=0.046) and CMR (15.8% versus 2.1%; P=0.027), with greater improvement in GLS, lower E/e', and less left atrial enlargement; no parameter differed between the arms at 1 month.
Conclusions: In AMI-CS, serial multimodality imaging characterized microvascular, tissue-level, and functional injury over 1 year. Cangrelor was associated with less acute MVO, lower remote native T1, and more complete recovery of LV function than crushed ticagrelor, without a difference in infarct size; these hypothesis-generating findings suggest differences in the microcirculation and non-infarcted myocardial injury but do not establish a treatment mechanism.
Cite This Study
Motovska et al. (2026) conducted an RCT in Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) (n=220). Intravenous cangrelor vs. Crushed oral ticagrelor was evaluated on Microvascular obstruction (MVO) on acute cardiac magnetic resonance (CMR) (OR 0.27, 95% CI 0.08-0.98, p=0.023). Intravenous cangrelor reduced the odds of acute microvascular obstruction on CMR compared with crushed ticagrelor in AMI-CS (adjusted OR 0.27; 95% CI 0.08-0.98; P=0.023).
