Perspectives on why DanGer Shock is the first positive trial on mechanical circulatory support in cardiogenic shock.

Cardiogenic shock related to acute myocardial infarction (AMI-CS) remains a severe condition associated with a high risk of mortality despite increased availability of primary percutaneous coronary intervention and improvements in pharmacologic and device-based therapy. The results of the DanGer Shock trial stand out compared with the outcomes of the previous trials and mark the first mechanical circulatory support (MCS) strategy to show a benefit in patients with AMI-CS, a population that has always been challenging to study. Notably, negative findings from previous trials may mask positive treatment effects in specific subgroups and patient category. We systematically reviewed the design of all contemporary randomized controlled AMI-CS trials and identified four distinct features, which likely provide reasons why DanGer Shock became the first positive randomized controlled trial to support MCS in AMI-CS. DanGer Shock was the first RCT that established MCS in the context of AMI-CS. Key features were (1) patient phenotype that 1)  includes STEMI and 2) excludes severe RV failure and persistent comatose state after out-of-hospital cardiac arrest; (3) optimal timing of MCS deployment, as soon as possible (lower SCAI stage) and before revascularization efforts; and (4) rigorous intensive care management protocols on hemodynamic and MCS monitoring.