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Treating Older Patients in Cardiogenic Shock with a Microaxial Flow Pump: Is it DANGERous?

Journal of the American College of Cardiology

Authors: Anika Klein, Rasmus P Beske, Christian Hassager, Lisette O Jensen, Hans Eiskjær, Norman Mangner, Axel Linke, Amin Polzin, P Christian Schulze, Carsten Skurk, Peter Nordbeck, Peter Clemmensen, Vasileios Panoulas, Sebastian Zimmer, Andreas Schäfer, Nikos Werner, Thomas Engstøm, Lene Holmvang, Anders Junker, Henrik Schmidt, Christian J Terkelsen, Jacob E Møller

BACKGROUND: Whether age impacts the recently demonstrated survival benefit of microaxial flow pump (mAFP) treatment in patients with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS) is unknown.

OBJECTIVES: The purpose of this study was to assess the impact of age on mortality and complication rates in patients with STEMI-related CS randomized to standard care or mAFP on top of standard care.

METHODS: This is a secondary analysis of the Danish-German Cardiogenic Shock (DanGer Shock) trial, an international, multicenter, open-label trial, in which 355 adult patients with STEMI-related CS were randomized to receive a mAFP (Impella CP) plus standard care or standard care alone. The primary outcome of 180-day all-cause mortality is analysed according to age and intervention.

RESULTS: From lowest to highest age quartile, the median ages (range) were: 54 (31-59), 65 (60-69), 73 (70-76), and 81 (77-92) years. There were no differences in blood pressure, lactate level, left ventricular ejection fraction or shock severity at randomization across age groups. Mortality increased from lowest to highest quartile (31%, 47%, 61%, and 73%, respectively; log-rank p<0.001), with an adjusted odds ratio (OR) for death at 180 days of 7.85 (95% CI, 3.37-19.2; p<0.001) in the highest quartile compared to the lowest. The predicted risk of mortality was higher in the standard-care group until approximately 77 years, after which the predicted risk became higher in the mAFP group (p-interaction=0.2). In patients younger than 77 years, a reduced 180-day mortality was observed in patients randomized to the mAFP (OR, 0.45; 95% CI, 0.28-0.73; p=0.001), opposed to patients aged 77 years or older (OR, 1.52; 95% CI, 0.57-4.08; p=0.40), p=0.028 for interaction. Complications were more frequent in the mAFP group, but there were no apparent differences in incidence of complications across all ages.

CONCLUSIONS: This exploratory secondary analysis of the DanGer Shock trial demonstrates that elderly patients with STEMI-related CS experience high mortality and may not attain the same benefit from routine treatment with a mAFP as younger patients. Incorporating age as a factor in patient selection may enhance the overall benefit of this therapy. (DanGer Shock, NCT01633502).

Copyright © 2024. Published by Elsevier Inc.

PMID: 39551167

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