Coronary complexity predicted death in shock, but did not change the effect of the heart pump

Design

Secondary analysis of the randomised DanGer Shock trial

Population

256 patients with infarct-related cardiogenic shock and multivessel disease (211 with a baseline SYNTAX score)

Primary outcome

180-day all-cause mortality

Effect

High vs low or intermediate baseline SYNTAX: adjusted OR 3.12 (95% CI 1.17 to 8.69); pump effect interaction p = 0.31

This secondary analysis of the DanGer Shock trial looked at 256 of 355 patients with infarct-related cardiogenic shock and multivessel disease, or an isolated left main culprit lesion. Of 211 with a baseline SYNTAX score, 26% were low (22 or less), 47% intermediate and 27% high (over 32). The outcome was 180-day mortality.

A high baseline SYNTAX score was associated with higher odds of death than low or intermediate scores (adjusted OR 3.12, 95% CI 1.17 to 8.69), and the residual SYNTAX score after revascularisation independently predicted death too. The effect of the microaxial flow pump was not modified by baseline SYNTAX group (interaction p = 0.31). In the 35 patients with an isolated left main culprit, pump use was associated with lower odds of death (adjusted OR 0.17, 95% CI 0.03 to 0.99), which the authors describe as hypothesis-generating.

The subgroup is small and the interval ends close to 1. Anatomy helps with prognosis and counselling, and does not by itself tell you whom to give the pump.

• A high baseline SYNTAX score (above 32) was associated with higher 180-day mortality (adjusted OR 3.12).
• Residual SYNTAX score after PCI also predicted death.
• Baseline SYNTAX did not change the effect of the microaxial pump (interaction p = 0.31).
• The isolated left main signal rests on 35 patients and is hypothesis-generating.
• Use anatomy for prognosis and family discussions, not as the only pump selection criterion.

Why it matters

It separates the question of how sick the coronary anatomy is from the question of who benefits from the pump.

Don't overread it

This is a secondary analysis of one trial and the left main subgroup is far too small to guide practice.

The statistics, in plain English

An odds ratio of 3.12 with a lower bound of 1.17 is statistically significant but imprecise. The isolated left main result (0.17, 0.03 to 0.99) has an interval that nearly includes 1 and is based on only 35 patients, so it is easily overturned.

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