Thursday Night Live: Highway to the DanGer Zone

In this Thursday Night Live event, Mitul Patel, Alexander Truesdell and Katherine Kunkel discuss the implications of the DanGer Shock randomized controlled trial (RCT) for community and academic centers in the United States.

Mitul Patel, M.D., FACC, FSCAI, an interventional cardiologist at Intermountain Healthcare in Salt Lake City, Utah, provides an overview of the DanGer Shock RCT, highlighting the results demonstrating an absolute 12.7% reduction in mortality at 180 days. He emphasizes that the trial number needed to treat (NNT) to save 1 life of 8 is “a very powerful result.” He briefly compares DanGer Shock to other landmark clinical trials in acute myocardial infarction cardiogenic shock (AMICS) and provides perspective on the trial’s survival NNT compared to other studies. Dr. Patel presents a case to “drive the data points home” and then discusses how to navigate Impella® use in a new institution.

Alexander Truesdell, M.D., from Virginia Heart / Inova Schar Heart and Vascular Institute in Falls Church, Virginia, discusses cardiogenic shock (CS) teams and how they fit with the new data from the DanGer Shock trial. He highlights the importance of early identification and risk stratification for CS, shock protocols and shock teams, how to look at escalating and transferring patients, how this fits with the concepts of shock centers and shock networks, and the value of institutions tracking their own outcomes. Dr. Truesdell emphasizes “the unfortunate reality” of wide variability in cardiogenic shock care across the United States, with undesired delays in recognition, barriers to access and heterogeneities of care within and between institutions. After touching on how shock teams are activated and coordinated at his institution, he summarizes, “act fast, phenotype and stage, reassess and escalate. More time in shock increases mortality.”

“The routine use of Impella reduced all-cause mortality at 180 days in AMI cardiogenic shock due to STEMI compared to standard of care alone,” Katherine Kunkel, M.D., MSEd, FACC, FSCAI, an interventional cardiologist at Piedmont Heart Institute in Atlanta, Georgia, states in the introduction to her presentation. “It’s really exciting after so long and so much research in this field to be able to make that sort of statement.” Yet she acknowledges that such a powerful statement comes with the need to understand the increase in adverse events in the Impella arm of the study, notably moderate/severe bleeding, limb ischemia, and temporary renal replacement therapy. Dr. Kunkel discusses how best practices, including strategies for vascular access and closure and assessing distal limb perfusion, can improve patient outcomes and reduce adverse events.

The event concludes with a moderated Q&A in which the physicians discuss topics ranging from changes they have seen in Impella use since the publication of the DanGer Shock data to anticoagulation management and escalation strategies.