Why is this study important?

Cardiogenic shock complicating acute myocardial infarction (AMI-CS) carries persistently high mortality. CERAMICS is the first multicenter study to prospectively evaluate a standardized protocol emphasizing early Impella support, invasive hemodynamic monitoring, and a defined MCS escalation pathway in PCI-capable shock centers.

The study demonstrates that a protocolized approach to early mechanical circulatory support with escalation capability is feasible and is associated with 71% overall survival to discharge, reinforcing the importance of early shock recognition and guideline-recommended therapies.

What question was this study supposed to answer?

Despite advances in revascularization and critical care, AMI-CS mortality remains unacceptably high, with in-hospital mortality rates historically ranging from 30–50%. While mechanical circulatory support devices such as Impella are increasingly used, there is limited prospective, multicenter data on outcomes when early MCS implantation is paired with a structured escalation strategy (e.g., Impella 5.5 or ECMO) in dedicated shock centers.

CERAMICS sought to determine whether a standardized protocol, centered on rapid Impella deployment, pulmonary artery catheter–guided hemodynamic management, and systematic MCS escalation could improve survival in this high-risk population.

What did the study show?

• Overall survival to discharge was 71% across 124 patients with AMI-CS treated at 20 centers using the standardized protocol.
• Survival was 78% in SCAI stage C/D shock and 60% in stage E shock, a population historically associated with very high mortality.
• The protocol achieved high adherence: 68% had MCS implanted prior to PCI, and 95% had pulmonary artery catheters placed for hemodynamic guidance.
• Median door-to-support time was 76 minutes and door-to-balloon time was 72 minutes, reflecting rapid initiation of both MCS and revascularization.
• MCS escalation was performed in 23% of patients (survival 57%), with escalation to Impella 5.5 (survival 58%) and ECMO (survival 70%) as the primary strategies.
• Complication rates were notable: blood transfusion was required in 47%, acute kidney injury occurred in 52%, and 21% required in-hospital dialysis.
• Outcomes were similar to previous reports from the National Cardiogenic Shock Initiative (NCSI), suggesting that the benefit of early MCS and protocolized care is reproducible across centers with escalation capabilities.
• The investigators concluded that the focus should remain on early shock recognition and delivery of guideline-recommended therapies, including Impella and PC, in PCI-capable hospitals.