Multimodality Cardiac Imaging Substudy of the DAPT-SHOCK-AMI Randomized Trial: Echocardiographic and Cardiac Magnetic Resonance Assessment of Cangrelor versus Crushed Ticagrelor in Cardiogenic Shock Complicating Acute Myocardial Infarction

BACKGROUND: In acute myocardial infarction complicated by cardiogenic shock (AMI-CS), the myocardium sustains a dual injury: ischemia of the culprit territory and global hypoperfusion from low cardiac output. Whether platelet inhibition at reperfusion affects the microcirculation, the infarct, the noninfarcted myocardium, and ventricular function, and over what time course, has not been examined with serial imaging. The prespecified multimodality imaging substudy of the randomized DAPT-SHOCK-AMI trial (intravenous cangrelor versus crushed oral ticagrelor) addressed this question. METHODS: Patients at prespecified imaging sites underwent serial echocardiography (208 enrolled; evaluable examinations in 175, 120, and 99 patients in the acute phase, at 1 month, and at 1 year) and cardiac magnetic resonance (CMR; 93 enrolled; 73, 68, and 63); 81 patients (40 and 41) underwent both modalities. Blinded core laboratories analyzed all studies. The primary imaging endpoint was microvascular obstruction (MVO) on acute CMR, evaluable in 60 patients; secondary endpoints were infarct size, native T1 of the global, infarcted, and remote myocardium, left ventricular (LV) ejection fraction (LVEF), global longitudinal strain (GLS), E/e', and left atrial volume, and their changes. Comparisons between the cangrelor and crushed ticagrelor arms used covariate-adjusted logistic or linear regression; the substudy was not separately powered. RESULTS: The odds of acute MVO were lower with cangrelor (adjusted odds ratio 0.27 [95% CI 0.08 to 0.98]; P=0.023). Infarct size did not differ between the arms. At 1 year, native T1 of the remote myocardium was lower with cangrelor (adjusted mean 1114 [95% CI 1057 to 1171] versus 1171 [1115 to 1228] ms; P=0.005). Over 1 year, LVEF increased more with cangrelor on echocardiography (37.9% versus 21.7% of the acute value; adjusted P=0.046) and CMR (15.8% versus 2.1%; P=0.027), with greater improvement in GLS, lower E/e', and less left atrial enlargement; no parameter differed between the arms at 1 month. CONCLUSIONS: In AMI-CS, serial multimodality imaging characterized microvascular, tissue-level, and functional injury over 1 year. Cangrelor was associated with less acute MVO, lower remote native T1, and more complete recovery of LV function than crushed ticagrelor, without a difference in infarct size; these hypothesis-generating findings suggest differences in the microcirculation and non-infarcted myocardial injury but do not establish a treatment mechanism.

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Journal
Circulation
Published
2026-11-07
DOI
https://doi.org/10.1161/circulationaha.126.083929
Primary Topic
Cardiac Imaging and Diagnostics
Type
article
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article

Multimodality Cardiac Imaging Substudy of the DAPT-SHOCK-AMI Randomized Trial: Echocardiographic and Cardiac Magnetic Resonance Assessment of Cangrelor versus Crushed Ticagrelor in Cardiogenic Shock Complicating Acute Myocardial Infarction

Petr Widimský, J. Weichet, Petr Klofáč, Deepak L. Bhatt et al.
4 links
Circulation
Cardiac Imaging and Diagnostics
article

Multimodality Cardiac Imaging Substudy of the DAPT-SHOCK-AMI Randomized Trial: Echocardiographic and Cardiac Magnetic Resonance Assessment of Cangrelor versus Crushed Ticagrelor in Cardiogenic Shock Complicating Acute Myocardial Infarction

Petr Widimský, J. Weichet, Petr Klofáč, Deepak L. Bhatt, Dana Kautznerová, Milan Hromádka, Oana Raluca Ioniţă, Teodora Vichova, Pavol Tomašov, Jiří Kettner, Marco Guglielmo, Gilles Montalescot, Andrea Andrášová, Roberto Tarantini, Jiří Jarkovský, Jan Bělohlávek, Libor Gajdůšek, Petr Kala, Nina Ajmone Marsan, Petr Kuchynka, Jan Baxa, Zuzana J Motovska, Tomáš Ondrúš, Robin Nijveldt, Jan Přeček, Martin Pěnička, Jan Lhotský, Roman Panovský, Martin Kotrč, Tobias Geisler, Martin Novák, Martin Mašek, Zbyněk Tüdös, Stanislav Bartus, Monika Cani
article en

Abstract

BACKGROUND: In acute myocardial infarction complicated by cardiogenic shock (AMI-CS), the myocardium sustains a dual injury: ischemia of the culprit territory and global hypoperfusion from low cardiac output. Whether platelet inhibition at reperfusion affects the microcirculation, the infarct, the noninfarcted myocardium, and ventricular function, and over what time course, has not been examined with serial imaging. The prespecified multimodality imaging substudy of the randomized DAPT-SHOCK-AMI trial (intravenous cangrelor versus crushed oral ticagrelor) addressed this question. METHODS: Patients at prespecified imaging sites underwent serial echocardiography (208 enrolled; evaluable examinations in 175, 120, and 99 patients in the acute phase, at 1 month, and at 1 year) and cardiac magnetic resonance (CMR; 93 enrolled; 73, 68, and 63); 81 patients (40 and 41) underwent both modalities. Blinded core laboratories analyzed all studies. The primary imaging endpoint was microvascular obstruction (MVO) on acute CMR, evaluable in 60 patients; secondary endpoints were infarct size, native T1 of the global, infarcted, and remote myocardium, left ventricular (LV) ejection fraction (LVEF), global longitudinal strain (GLS), E/e', and left atrial volume, and their changes. Comparisons between the cangrelor and crushed ticagrelor arms used covariate-adjusted logistic or linear regression; the substudy was not separately powered. RESULTS: The odds of acute MVO were lower with cangrelor (adjusted odds ratio 0.27 [95% CI 0.08 to 0.98]; P=0.023). Infarct size did not differ between the arms. At 1 year, native T1 of the remote myocardium was lower with cangrelor (adjusted mean 1114 [95% CI 1057 to 1171] versus 1171 [1115 to 1228] ms; P=0.005). Over 1 year, LVEF increased more with cangrelor on echocardiography (37.9% versus 21.7% of the acute value; adjusted P=0.046) and CMR (15.8% versus 2.1%; P=0.027), with greater improvement in GLS, lower E/e', and less left atrial enlargement; no parameter differed between the arms at 1 month. CONCLUSIONS: In AMI-CS, serial multimodality imaging characterized microvascular, tissue-level, and functional injury over 1 year. Cangrelor was associated with less acute MVO, lower remote native T1, and more complete recovery of LV function than crushed ticagrelor, without a difference in infarct size; these hypothesis-generating findings suggest differences in the microcirculation and non-infarcted myocardial injury but do not establish a treatment mechanism.

Circulation
Jagiellonian University (PL), Inserm (FR), Utrecht University (NL), Charles University (CZ), Masaryk University (CZ), Leiden University Medical Center (NL), University Medical Center Utrecht (NL), Sorbonne Université (FR), Universitätsklinikum Tübingen (DE), Assistance Publique – Hôpitaux de Paris (FR), University Hospital Brno (CZ), University Hospital Olomouc (CZ), Krajská Nemocnice Liberec (CZ), International Clinical Research Center, St. Anne's University Hospital Brno (CZ), Pitié-Salpêtrière Hospital (FR), Nemocnice Podlesí (CZ), Institute of Clinical and Experimental Medicine (CZ), St. Anne's University Hospital Brno (CZ), Centire (SK), University Hospital Kralovske Vinohrady (CZ), General University Hospital in Prague (CZ), Liberec Region (CZ), Palacký University Olomouc (CZ), University of Tübingen (DE), Icahn School of Medicine at Mount Sinai (US)
Ministerstvo Zdravotnictví Ceské Republiky, NextGenerationEU
Good health and well-being
Openalex Percentile: Top 17%
Cardiac Imaging and Diagnostics
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