Cangrelor versus crushed ticagrelor in acute myocardial infarction complicated by cardiogenic shock (DAPT-SHOCK-AMI): a randomised, double-blind trial

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• Picked for Cardiology and Cardiovascular Medicine (paper of the day, 8 November 2026): IV cangrelor vs oral ticagrelor in shock

Abstract

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) can compromise the administration and absorption of oral P2Y12 inhibitors and carries high ischaemic and mortality risks. This trial assessed whether intravenous cangrelor was non-inferior to crushed oral ticagrelor for short-term clinical outcomes and whether it provided faster and more consistent platelet inhibition in patients with AMI-CS. METHODS: DAPT-SHOCK-AMI was a double-blind trial conducted at 29 hospitals across five European countries (Czech Republic, France, Germany, Poland, and Slovakia). Patients older than 18 years with AMI-CS were randomly assigned (1:1 ratio, stratified by centre, age, sex, presence or absence of ST-segment elevation, and mechanical ventilation) to cangrelor (30 μg/kg bolus followed by an infusion of 4 μg/kg per min for at least 2 h) or crushed ticagrelor (180 mg loading dose). The primary laboratory endpoint was a platelet reactivity index of less than 50% at the end of primary percutaneous coronary intervention. The primary clinical endpoint was death, myocardial infarction, or ischaemic stroke at 30 days. The primary clinical endpoint was analysed for non-inferiority with a prespecified margin of 1 percentage point among all randomly assigned patients who received study treatment. The study is registered with ClinicalTrials.gov (NCT03551964) and EudraCT (2018-002161-19); recruitment and 1-year follow-up are complete, and 5-year follow-up is ongoing. FINDINGS: Between Aug 1, 2018, and Jan 19, 2024, 605 patients (137 [23%] were female) were randomly assigned to cangrelor (n=298) or ticagrelor (n=307); no surviving patients were lost to the 1-year follow-up. The primary laboratory endpoint was analysed in 56 (19%) patients in the cangrelor group and 68 (22%) in the ticagrelor group, and was achieved in 56 (100%) of 56 patients receiving cangrelor and 15 (22%) of 68 receiving ticagrelor (p<0·0001). The 30-day primary clinical endpoint occurred in 112 (38%) of 298 patients receiving cangrelor and 126 (41%) of 307 receiving ticagrelor; non-inferiority was not demonstrated (difference -4 percentage points [90% CI -10 to 3]; Pnon-inferiority=0·13). Major bleeding at 30 days occurred in 19 (6%) of 298 patients receiving cangrelor and 16 (5%) of 307 receiving ticagrelor. INTERPRETATION: To our knowledge, this is the first randomised trial to compare P2Y12 inhibitor strategies specifically in patients with AMI-CS. Cangrelor achieved effective platelet inhibition more frequently than crushed ticagrelor at the end of primary percutaneous coronary intervention. Non-inferiority of cangrelor versus crushed ticagrelor was not demonstrated for the primary 30-day clinical endpoint. These trial findings can inform future trials of P2Y12 inhibition strategies in patients with AMI-CS. FUNDING: Czech Republic Ministry of Health, Charles University (Czech Republic), and NextGenerationEU.

Abstract as published, via PubMed.