Treatment of ST-elevation myocardial infarction complicated by cardiogenic shock
Clinical scenario
Acute ST-elevation myocardial infarction (STEMI) demands rapid intervention. When cardiogenic shock develops as a complication, the clinical urgency intensifies — decisions about vascular access, reperfusion strategy, and circulatory management must be made quickly and in sequence.
Cardiogenic shock — the defining complication
The co-occurrence of cardiogenic shock with STEMI substantially alters the management pathway. Early revascularization of the infarct-related territory is supported by randomised trial evidence and is the central priority in this scenario.
Approach (partial overview only)
Early revascularization forms the cornerstone, with the infarct-related artery as the primary procedural focus. The specific reperfusion strategy is guided by catheterization availability and the time elapsed since diagnosis. In the most severe or refractory presentations, additional mechanical support options enter consideration.
The complete protocol — including the full decision pathway, all options, and their sequencing — is available below.
References
DOI: 10.1093/eurheartj/ehad191
- Early revascularization with either PCI or CABG is recommended for patients with AMI complicated by CS, based on the results of the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial.
- Immediate coronary angiography and PCI of the IRA (if indicated) is recommended in patients with CS complicating ACS.
- PCI during the index procedure should be restricted to the IRA only.
- Fibrinolysis should be considered in STEMI patients presenting with CS if a PPCI strategy is not available within 120 min from the time of STEMI diagnosis and mechanical complications have been ruled out.
- In patients with ACS and severe/refractory CS, short-term mechanical circulatory support may be considered.
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