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Contemporary treatment of acute myocardial infarction complicated by cardiogenic shock

Despite major advances in the treatment of myocardial infarction (MI), the incidence of cardiogenic shock has remained unchanged, complicating 7% to 10% of acute myocardial infarctions (MI) [1] and constituting the leading cause of death in patients with acute MI [1]. During the last three decades, the hospital mortality rates from cardiogenic shock have declined from as high as 90% to 50%. These improvements are attributed to the many changes in clinical practice that occurred during this period, and in particular, early coronary revascularization and more aggressive use of circulatory support devices. The 50% mortality rate from cardiogenic shock is still substantial. The contemporary approach to cardiogenic shock complicating MI is reviewed in this article.
Early revascularization
Early mechanical reperfusion of occluded coronary arteries by percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) appears to be key for survival of patients with cardiogenic shock. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) was the first multicenter, prospective study that evaluated early revascularization (PCI or CABG) in patients with cardiogenic shock due to an ST-elevation/Q-wave or new left bundle branch block MI, which compared outcomes to either delayed revascularization or medical treatment [2]. The overall 30-day mortality did not differ significantly between the revascularization and the medical therapy groups, but the 6-month and 12-month mortality were significantly lower in the revascularization group (Fig. 1). One-year follow-up of the SHOCK trial [3] and the later study by Sleeper et al. [4] showed that early revascularization not only provided substantial survival benefit in these patients, but also resulted in much better long-term quality of life and fewer symptoms of heart failure. Percutaneous coronary intervention (PCI) is the first line of therapy in acute cardiogenic shock (Tab. I) [5]. Rapid transfer of patients to the catheterization lab allows not only early opening of the occluded vessel, but also assessment of hemodynamics and temporary stabilization with an intraaortic counterpulsation balloon pump (IABP). Some patients considered CABG candidates may also undergo during this time a PCI of the diseased vessels as a measure of temporarily stabilization before surgery. The SHOCK trial revealed that as many as one third (37%) of catheterized patients...


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