Pragmatic DanGer Shock Eligibility, Outcomes, and Costs in Acute Myocardial Infarction: A Nationwide Cohort Study.

BACKGROUND: In-hospital mortality remains 45% among patients with acute myocardial infarction (AMI)-related cardiogenic shock despite advances in mechanical circulatory support (MCS), including microaxial flow pumps and venoarterial extracorporeal membrane oxygenation. These findings suggest that not all patients benefit from MCS. OBJECTIVES: This study aimed to identify patients less likely to benefit from MCS based on pragmatically approximated Danish-German Cardiogenic Shock trial (pDanGer) eligibility. METHODS: Using a Japanese nationwide administrative dataset (JROAD-DPC [Japanese Registry Of All cardiac and vascular Diseases-Diagnostic Procedure Combination]) from 2022 to 2023, we evaluated the association of pDanGer eligibility with in-hospital mortality, failure to be discharged home, and medical costs; pDanGer eligibility was defined by the absence of mechanical complications, out-of-hospital cardiac arrest with persistent coma, and severe dementia. RESULTS: Of 52,927 AMI patients, 2,226 were treated with MCS. Among them, in-hospital death and failure to be discharged home were identified in 1,339 (pDanGer-eligible, 945; ineligible, 394) and in 379 (pDanGer-eligible, 281; ineligible, 98), respectively. The median follow-up was 11 days (IQR: 8-16). pDanGer eligibility was associated with lower in-hospital mortality (adjusted OR [aOR]: 0.58; 95% CI: 0.47-0.73) and lower failure to be discharged home (aOR: 0.37; 95% CI: 0.25-0.54). Medical costs were higher in pDanGer-ineligible survivors and those discharged home, while among patients who died, costs were higher in pDanGer-eligible patients. CONCLUSIONS: pDanGer eligibility was associated with lower in-hospital mortality and failure to be discharged home among AMI patients treated with MCS. In contrast, ineligible patients incurred substantial medical costs, highlighting the importance of appropriate patient selection for MCS use.