ACS GUIDELINES
ACC/AHA Upgrades mAFP to Class 2a and Downgrades IABP and VA-ECMO to Class 3
Recommendations for MCS in Patients with ACS and Cardiogenic Shock
The new Acute Coronary Syndrome (ACS) guidelines downgrade intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) to Class 3 due to no shown benefit, while microaxial intravascular flow pumps (mAFP), Impella®, is now Class 2a in patients with STEMI and severe or refractory cardiogenic shock.
The guideline upgrade for Impella is based on evidence from the DanGer Shock RCT, published in the New England Journal of Medicine and the first AMI cardiogenic shock (AMICS) trial to achieve its primary survival endpoint.1,5
- Overall: 26% relative risk reduction, NNT 8 (p=0.04)1
- Patients < 77 years: 35.7% relative risk reduction, NNT 5 (p=0.001)2,3
- Impella CP promotes faster lactate clearance and reduces dependency on vasoactive drugs, improving patient outcomes4
- Adverse events in DanGer Shock are transient: Bleeding was not associated with an impact on survival, no patients required dialysis at six months and outcomes can be further optimized with best practices and technologies1
References
- Møller J, et al. (2024). Microaxial Flow Pump or Standard Care in Infarct-Related CS. N Engl J Med. DOI: 10.1056/NEJMoa2312572
- Klein, A., et al. DanGer Shock Investigators (2024). Treating Older Patients in Cardiogenic Shock with a Microaxial Flow Pump: Is it DANGERous?. Journal of the American College of Cardiology, S0735-1097(24)10416-0. Advance online publication. https://doi.org/10.1016/j.jacc.2024.11.003
- Klein, A., et al. DanGer Shock Investigators (2024). Treating Older Patients in Cardiogenic Shock with a Microaxial Flow Pump: Is it DANGERous? SUPPLEMENTAL APPENDIX. Journal of the American College of Cardiology, S0735-1097(24)10416-0. Advance online publication. https://doi.org/10.1016/j.jacc.2024.11.003
- Udesen NLJ, et al. Microaxial Flow Pump Hemodynamic and Metabolic Effects in Infarct-Related Cardiogenic Shock: A Substudy of the DanGer Shock Randomized Clinical Trial. JAMA Cardiol. (2024). doi:10.1001/jamacardio.2024.4197
- Rao, SV, et al. (2025). ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients with Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. https://pubmed.ncbi.nlm.nih.gov/40013746/
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