4.2 STEMI-CS: Any "DanGer" to Unloading Routinely? Complete or CULPRIT Revascularization? Are Shock Teams Needed? How to Handle the Antiplatelet/Anticoagulation Therapy?
Problem Presenter: Alex Truesdell for Rajan Patel
Problem Presenter: Alex Truesdell for Rajan Patel
These proceedings summarize the educational activity of the 18th Biennial Meeting of the International Andreas Gruentzig Society held January 27 to 30, 2026, in Puerto Ayora, Santa Cruz, Ecuador.
Faculty Disclosures Sponsors
2026 IAGS Summary Document
Statement of problem or issue
The DanGer-Shock randomized controlled trial showed a mortality benefit (lower mortality) at 6 months from routine use of mechanical circulatory support (MCS) with a microaxial flow pump among STEMI patients in advanced stages of cardiogenic shock (CS).[1,2] Yet, many questions still remain to be answered. Despite the superior survival in the MCS group, the “danger” encountered in the trial included higher rates of adverse events in the group randomly assigned to MCS compared with those assigned to Standard Care alone (Table 1).[1] These risks were approximately double in MCS patients compared with standard care patients. However, it also be noted that no patients were on renal replacement therapy at 6 months. Also importantly, the increase in bleeding events in the MCS group did not result in increased mortality.
|
Outcome |
MCS + Standard Care (%) |
Standard Care alone (%) |
HR |
|
1° endpoint: death at 180 days |
45.8 |
58.5 |
0.74 |
|
Adverse events: |
|
|
|
|
Moderate or severe bleeding |
21.8 |
11.9 |
2.06 |
|
Limb ischemia |
5.6 |
1.1 |
5.15 |
|
Renal replacement therapy |
41.9 |
26.7 |
1.98 |
|
Sepsis with (+) blood culture |
11.7 |
4.5 |
2.79 |
Table 1. Primary outcomes and adverse event rates in the DanGer Shock trial. Adapted from Møller JE, et al; DanGer Shock Investigators. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. N Engl J Med. 2024;390(15):1382-1393. Used with permission.
In the DanGer Shock trial, approximately one-half of the patients in both groups underwent non-culprit lesion revascularization in addition their primary PCI. This decision was left to operator discretion. Subgroup analysis did not reveal any important insights. However, the COMPLETE trial showed a benefit with complete revascularization in patients with STEMI. [3] Although CS was an exclusion criterion in COMPLETE, subgroup analysis showed benefits with complete revascularization in patients with reduced ejection fractions and those with Killip Class ≥2. On the other hand, the CULPRIT-SHOCK trial showed that in patients with STEMI and CS, culprit-lesion only PCI was superior to complete revascularization.[4] However, staged or urgent repeat revascularizations were not part of the trial design in CULPRIT-SHOCK, were left to clinical judgment, and the culprit-lesion only group had more of these (Table 2). So, the full answers on culprit-only or complete revascularization in patients with STEMI-CS remain unknown.
|
Outcome |
Culprit lesion only PCI (%) |
Multivessel PCI (%) |
Relative risk
|
P-value |
|
Staged or |
21.5 |
3.8 |
7.43 |
<.001 |
Table 2. Staged or urgent repeat revascularizations in the CULPRIT-SHOCK trial. Adapted from Thiele H, et al; CULPRIT-SHOCK Investigators. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med. 2017;377(25):2419-2432. Used with permission.
There is evidence that shock protocols providing structured patient management, along with the implementation of specialized Shock Teams, improves patient care and reduces adverse events compared with non-protocolized care. [6,7]
Gaps in current knowledge
- Shock teams
- How can they be created, developed, and maintained?
- How to maintain quality of care?
- Are they sustainable? Scalable? Transferable?
- Culprit-only, Immediate complete, Staged complete revascularization?
- Are bleeding events related to antithrombotic therapies? How to manage?
- Antiplatelet
- Anticoagulant
Possible solutions or future directions
The use of protocolized care with adoption of best practices (including large bore access and closure) is being examined in the OASIS-AMICS trial (NCT06964685).
Some new information on culprit/complete revascularization, and timing, will come from the COMPLETE-2 trial (NCT05701358). Nevertheless, additional studies are needed.
The area of antithrombotic therapies in STEMI-CS is wide open.[8,9] While bowel absorption of oral agents is known to be decreased in patients with CS, the timing and markers of bowel recovery are unknown. Some research studies have examined the use of intravenous (IV) antiplatelet agents as an alternative to oral agents. However, the recently completed DAPT-SHOCK-AMI trial found more potent platelet inhibition, better coronary flow, fewer PCI complications, and lower rates of major bleeding with the IV antiplatelet agent cangrelor compared with oral ticagrelor; nevertheless, there was no difference in the primary outcome of death+MI+ischemic stroke at 30 days. [10] This should be an active area for future investigations.
References
- Møller JE, et al; DanGer Shock Investigators. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. N Engl J Med. 2024;390(15):1382-1393. doi: 10.1056/NEJMoa2312572. Epub 2024 Apr 7. PMID: 38587239.
- Kapur NK, et al. Criteria for Defining Stages of Cardiogenic Shock Severity. J Am Coll Cardiol. 2022 Jul 19;80(3):185-198. doi: 10.1016/j.jacc.2022.04.049. PMID: 35835491.
- Mehta SR, et al; COMPLETE Trial Steering Committee and Investigators. Complete Revascularization with Multivessel PCI for Myocardial Infarction. N Engl J Med. 2019 Oct 10;381(15):1411-1421. doi: 10.1056/NEJMoa1907775. Epub 2019 Sep 1. PMID: 31475795.
- Thiele H, et al; CULPRIT-SHOCK Investigators. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med. 2017;377(25):2419-2432. doi: 10.1056/NEJMoa1710261. Epub 2017 Oct 30. PMID: 29083953.
- Basir MB, et al; National Cardiogenic Shock Initiative Investigators. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv. 2019 Jun 1;93(7):1173-1183. doi: 10.1002/ccd.28307. Epub 2019 Apr 25. PMID: 31025538.
- Warren AF, et al. Cardiogenic Shock: Protocols, Teams, Centers, and Networks. US Cardiol. 2021 Oct 20;15:e18. doi: 10.15420/usc.2021.10. PMID: 39720489.
- Sinha SS, et al. 2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Evaluation and Management of Cardiogenic Shock: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2025 Apr 29;85(16):1618-1641. doi: 10.1016/j.jacc.2025.02.018. Epub 2025 Mar 17. PMID: 40100174.
- Droppa M, Geisler T. Optimal Antithrombotic Strategies in Cardiogenic Shock. J Clin Med. 2024 Jan 3;13(1):277. doi: 10.3390/jcm13010277. PMID: 38202284.
- D'Andria Ursoleo J, et al. Anti-Platelet Therapy with Cangrelor in Cardiogenic Shock Patients: A Systematic Review and Single-Arm Meta-Analysis. Medicina (Kaunas). 2024 Dec 21;60(12):2092. doi: 10.3390/medicina60122092. PMID: 39768971.
- www.pcronline.com/News/Congress-coverages/ESC/2025/DAPT-SHOCK-AMI-trial-Cangrelor-in-cardiogenic-shock. Accessed march 14, 2026.
© 2026 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.
