DAPT-SHOCK-AMI: Cangrelor Associated With Greater Recovery of Heart Function in Cardiogenic Shock Imaging Substudy
DAPT-SHOCK-AMI findings presented at AHA 2026 suggest differences in myocardial recovery compared with crushed ticagrelor; the main trial did not establish noninferiority for its primary clinical endpoint
DAPT-SHOCK-AMI findings presented at AHA 2026 suggest differences in myocardial recovery compared with crushed ticagrelor; the main trial did not establish noninferiority for its primary clinical endpoint
Patients with acute myocardial infarction complicated by cardiogenic shock who received intravenous cangrelor had less microvascular obstruction and greater recovery of left ventricular function than those receiving crushed oral ticagrelor, according to a prespecified imaging substudy of the randomized DAPT-SHOCK-AMI trial.
The findings were presented at the American Heart Association Scientific Sessions 2026 and simultaneously published in Circulation. The main trial was simultaneously published in The Lancet. The imaging findings are hypothesis-generating and do not establish that cangrelor improves survival or prevents heart failure.
Deepak L. Bhatt, MD, MPH, MBA, Director of Mount Sinai Fuster Heart Hospital and the Dr. Valentin Fuster Professor of Cardiovascular Medicine at the Icahn School of Medicine at Mount Sinai, is the senior and corresponding author. First author Zuzana Motovska, MD, PhD, of Charles University and University Hospital in Prague, Czechia, presented the findings.
Cardiogenic shock occurs when the heart cannot pump enough blood to meet the body’s needs. In patients with myocardial infarction, impaired circulation can also compromise the administration and absorption of oral antiplatelet medications. DAPT-SHOCK-AMI compared intravenous cangrelor with crushed oral ticagrelor to assess platelet inhibition and clinical outcomes in this high-risk population.
“This is the largest randomized trial of antiplatelet strategies in cardiogenic shock to date. Our findings should help inform the design of future trials in this difficult-to-study population,” said Dr. Bhatt.
The double-blind trial randomized 605 patients undergoing primary percutaneous coronary intervention: 298 to cangrelor and 307 to crushed ticagrelor. The primary laboratory endpoint was effective platelet inhibition, defined as a platelet reactivity index below 50% at the end of the procedure. Among patients tested, this endpoint was achieved in all 56 patients receiving cangrelor and in 15 of 68 patients receiving ticagrelor, or 22%.
The primary clinical endpoint, a composite of death, myocardial infarction, or ischemic stroke at 30 days, occurred in 112 patients receiving cangrelor, or 38%, and 126 receiving ticagrelor, or 41%. Noninferiority of cangrelor was not demonstrated for this endpoint. Major bleeding at 30 days occurred in 6% and 5% of patients, respectively.
The imaging substudy used serial echocardiography and cardiac magnetic resonance imaging, analyzed by blinded core laboratories, to examine myocardial injury and recovery over one year. It enrolled 208 patients for echocardiography and 93 for cardiac magnetic resonance imaging, with the number of evaluable examinations varying by time point.
The primary imaging endpoint, microvascular obstruction on acute cardiac magnetic resonance imaging, was evaluable in 60 patients. Cangrelor was associated with 73% lower adjusted odds of microvascular obstruction compared with ticagrelor (adjusted odds ratio, 0.27; 95% confidence interval, 0.08–0.98). Microvascular obstruction can impair blood flow through the heart’s small vessels despite reopening the blocked coronary artery. Infarct size did not differ between treatment groups.
Over one year, echocardiography showed a greater relative increase in left ventricular ejection fraction with cangrelor: 37.9% of the acute value compared with 21.7% with ticagrelor. Cardiac magnetic resonance imaging also showed greater improvement in left ventricular ejection fraction with cangrelor. No measured imaging parameter differed between groups at one month.
The substudy was not separately powered, and its findings do not establish the mechanism responsible for the observed differences. Further research is needed to determine whether the imaging findings translate into clinical benefits.
“Beyond the findings regarding cangrelor, this trial establishes the value of serial echocardiography and MRI in characterizing recovery from cardiogenic shock, one of the most lethal conditions in medicine. Future studies can use the approaches we studied here to evaluate novel therapies for cardiogenic shock,” Dr. Bhatt said.
Five-year follow-up of DAPT-SHOCK-AMI is ongoing. The findings may help inform the design of future trials evaluating antiplatelet strategies in patients with myocardial infarction complicated by cardiogenic shock.
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