The year 2025 was a landmark year for cardiogenic shock (CS) and mechanical circulatory support (MCS). Two major clinical guideline documents were published, the longest-duration follow-up data from the field's pivotal trial were released, and real-world registries continued to challenge trial generalizability. For cardiac intensive care unit (CICU) clinicians, these developments carry direct implications—and raise questions that will define the next decade of investigation.

DanGer Shock: The Long View

The DanGer Shock (Microaxial Flow Pump in Infarct-Related Cardiogenic Shock) trial—the largest randomized controlled trial (RCT) of temporary MCS in acute myocardial infarction–related cardiogenic shock (AMI-CS)—encompassed 355 patients with ST-segment elevation myocardial infarction–related cardiogenic shock (STEMI-CS; left ventricular [LV] ejection fraction <45%, lactate level ≥2.5 mmol/L or oxygen saturation <55%, systolic blood pressure <100 mm Hg or vasopressor use). The trial findings demonstrated that Impella CP (JNJ Medtech) reduced 180-day mortality by 12.7% versus standard care.¹ At ESC Congress 2025, 10-year follow-up findings published simultaneously by Møller et al. confirmed durability: 52.5% versus 68.8% mortality (hazard ratio, 0.7; 95% confidence interval [CI], 0.54-0.92), with patients with Impella gaining a mean of approximately 600 additional days alive (95% CI, 235-966 days).² The proportional hazard remained stable, suggesting benefit did not attenuate over time.

Important caveats apply. Causes of death after 6 months were not adjudicated. The trial population was highly selected—excluding out-of-hospital cardiac arrest–associated coma, right ventricular failure, and mechanical complications—limiting applicability to the broader population with AMI-CS.² Real-world data reinforce this concern: Among 3,975 patients with AMI-CS in the J-PVAD (Japanese Registry for Percutaneous Ventricular Assist Devices) in Japan from 2020 through 2023, a substantial proportion would not have met eligibility criteria and outcomes varied considerably across subgroups.³

Two Guideline Documents Reframe the Landscape

Two major policy publications in 2025 directly addressed CS management.

The 2025 ACC/AHA/Multisociety Guideline for the Management of Patients With Acute Coronary Syndromes incorporates DanGer Shock trial findings as the evidentiary basis for updated MCS recommendations.⁴ The use of microaxial flow pumps was upgraded to Class 2a for select patients with AMI-CS. Routine intra-aortic balloon pump was downgraded to Class 3 (no benefit). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was similarly downgraded, consistent with the results of the ECLS-SHOCK (ExtraCorporeal Life Support for acute myocardial infarction complicated by cardiogenic shock) trial.⁵ The guideline emphasized that structured weaning and vascular access protocols are essential to offset risks of bleeding, limb ischemia, and kidney failure.

The 2025 ACC Expert Consensus Statement on the Evaluation and Management of CS, the ACC's first in a new point-of-care policy format, recommends norepinephrine as first-line vasopressor, endorses invasive hemodynamic monitoring to guide escalation, and calls for early transfer of patients with refractory cases to Level 1 shock centers.⁶

The VA-ECMO Evidence Gap Persists

The evidence base for VA-ECMO remains sobering. Findings from the ECLS-SHOCK trial—the largest VA-ECMO RCT in AMI-CS—showed no mortality reduction with early, unselected implantation,⁵ and findings from the ECMO-CS (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) trial showed no benefit in a mixed population with CS.⁷ Both the 2025 ACC/AHA/multisociety guideline on acute coronary syndromes and the 2025 ACC expert consensus statement on CS reflected these neutral signals.^4,6 VA-ECMO use continues to grow in practice despite the absence of a randomized mortality signal. The ANCHOR (Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock) trial remains ongoing; the UNLOAD ECMO (Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO) trial—comparing Impella-adjunct LV unloading versus VA-ECMO alone—is expected to report in the near term.

A Pearl for the CICU Clinician

A consistent theme across both guidelines is that CS is not a static diagnosis. The 2025 ACC expert consensus statement on CS reinforces the Society for Angiography and Coronary Intervention (SCAI) SHOCK stage classification—updated with a three-axis model incorporating etiology, phenotype, and nonmodifiable risk factors—as a practical framework for serial reassessment and escalation decisions.⁶ Early hemodynamic characterization and prompt initiation of pharmacological and temporary MCS therapy based on risk stratification remain cornerstones of CICU management.

What Is on the Horizon

In 2026, key questions remain unanswered: Optimal axial flow pump timing (before vs. after percutaneous coronary intervention; non-STEMI–related CS) has not been established in RCT data, and MCS in non-AMI etiologies (decompensated heart failure, myocarditis, postcardiotomy shock) remains driven largely by observational data.^1,6 The devices are increasingly evidence supported, but the clinical judgment required to select the right patient, deploy support at the right time, manage complications, and execute structured weaning cannot be protocolized away.

References

1. Møller JE, Engstrøm T, Jensen LO, et al. Microaxial flow pump or standard care in infarct-related cardiogenic shock. N Engl J Med. 2024;390(15):1382-1393. doi:10.1056/NEJMoa2312572
2. Møller JE, Beske RP, Engstrøm T, et al. Long-term outcomes of the DanGer Shock trial. N Engl J Med. 2025;393(10):1037-1038. doi:10.1056/NEJMc2508284
3. Arai R, Kojima K, Fukamachi D, Okumura Y. DanGer shock criteria and outcomes in acute myocardial infarction-related cardiogenic shock treated with Impella: the J-PVAD Registry. Eur Heart J. 2026;47(4):472-486. doi:10.1093/eurheartj/ehaf787
4. Rao SV, O'Donoghue ML, Ruel M, 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. J Am Coll Cardiol. 2025;85(22):2135-2237. doi:10.1016/j.jacc.2024.11.009
5. Thiele H, Zeymer U, Akin I, et al. Extracorporeal life support in infarct-related cardiogenic shock. N Engl J Med. 2023;389(14):1286-1297. doi:10.1056/NEJMoa2307227
6. Sinha SS, Morrow DA, Kapur NK, Kataria R, Roswell RO. 2025 concise clinical guidance: an ACC expert consensus statement on the evaluation and management of cardiogenic shock: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2025;85(16):1618-1641. doi:10.1016/j.jacc.2025.02.018
7. Ostadal P, Rokyta R, Karasek J, et al. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial. Circulation. 2023;147(6):454-464. doi:10.1161/CIRCULATIONAHA.122.062949