Comparative efficacy and safety of mechanical circulatory support in ST-elevation myocardial infarction with cardiogenic shock: a network meta-analysis

Background ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock carries high mortality, yet optimal treatment remains uncertain in this distinct patient population. The aim of this study is to systematically evaluate and compare the efficacy of mechanical circulatory support (MCS) devices, vasoactive agents, and inotropic agents in the management of critical adult patients with STEMI complicating cardiogenic shock. Methods A network meta-analysis (PROSPERO CRD420251002524) was conducted, with systematic searches of six databases (Embase, Web of Science, PubMed, and Cochrane, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform) from inception to March 2025 for randomized and observational studies. We also updated the search to September 2026 using the same search strategy. Results Data from 22 studies (pooled n = 360,235) revealed a predominantly male (65%), older adult population (mean age 67 years), US-based (97.9%) population with hypertension, hyperlipidemia, diabetes or heart failure. Compared with intra-aortic balloon pump (IABP), based on observational evidence, Impella was associated with a significantly higher risk of short-term mortality (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.49–1.89), bleeding (OR 1.62, 95% CI 1.49–1.75), stroke (OR 2.67, 95% CI 1.01–7.03), AKI (OR 1.55, 95% CI 1.10–2.18), and AKI requiring dialysis (OR 1.67, 95% CI 1.50–1.87). Compared with control, Impella significantly increased the risk of stroke (OR 4.37, 95% CI 3.74–5.11). Randomized controlled trials (RCTs) have also supported an increased bleeding risk with Impella compared with IABP or standard care. Conclusion For STEMI patients with cardiogenic shock, IABP may be considered as a mechanical support option when hemodynamically feasible. By contrast, Impella has been associated with an unfavorable risk-benefit profile in this population in observational studies, which may be heavily influenced by patient selection and salvage use. Therefore, its application warrants careful consideration if escalation is necessary. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251002524 , PROSPERO CRD420251002524.