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Update in the Management of Acute Coronary Syndrome Patients with Cardiogenic Shock

  • Management of Acute Coronary Syndromes (H Jneid, Section Editor)
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Abstract

Purpose of Review

We provide a concise update on the contemporary management of cardiogenic shock in the setting of acute coronary syndrome (ACS). Early shock recognition, optimal selection and initiation of mechanical circulatory support (MCS), early coronary revascularization, and a team-based, protocol-driven approach are the current pillars of management.

Recent Findings

Cardiogenic shock complicates approximately 5–10% of ACS cases and continues to have high mortality. Early use of mechanical circulatory may prevent the downward spiral of shock and has significantly increased over time, supported mainly by registry data. In the CULPRIT-SHOCK trial, culprit-only revascularization was associated with a lower 30-day incidence of all-cause death or severe renal failure, compared with immediate multivessel PCI. Routine revascularization of non-infarct related artery lesion(s) during primary PCI for cardiogenic shock is, therefore, not recommended. The routine use of an intra-aortic balloon pump (IABP) was not associated with improved outcomes in the IABP-SHOCK II trial. A team-based and protocol-driven approach may further improve outcomes.

Summary

Recent advances in coronary revascularization and use of MCS, implementation of shock teams and standardized protocols may improve outcomes of cardiogenic shock in ACS patients.

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Abbreviations

ACS:

Acute coronary syndrome

AMICS:

Acute myocardial infarction complicated with cardiogenic shock

CAD:

Coronary artery disease

CPO:

Cardiac power output

CS:

Cardiogenic shock

CTO:

Chronic total occlusion

CULPRIT-SHOCK:

Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock

cVAD:

Catheter-based ventricular assist device

CVP:

Central venous pressure

e-CPR:

Extracorporeal cardiopulmonary resuscitation

IABP:

Intra-aortic balloon pump

IABP-SHOCK II:

Intra-aortic Balloon Pump in Cardiogenic Shock II

IMPRESS:

Impella versus IABP Reduces mortality in STEMI patients treated with primary PCI in severe cardiogenic SHOCK

MCS:

Mechanical circulatory support

AMI:

Acute myocardial infarction

PAPi:

Pulmonary Artery Pulsatility Index

RIFLE-STEACS:

Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome

RV:

Right ventricular

SBP:

Systolic blood pressure

SHOCK:

Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock

STEMI:

ST segment elevation acute myocardial infarction

VA-ECMO:

Veno-arterial extracorporeal membrane oxygenation

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Authors and Affiliations

  1. Vanderbilt University Medical Center, Nashville, TN, USA

    Jayant Bagai

  2. Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, 920 E 28th Street #300, Minneapolis, MN, 55407, USA

    Emmanouil S. Brilakis

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Correspondence to Emmanouil S. Brilakis.

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Jayant Bagai declares no conflict of interest.

Emmanouil S. Brilakis reports the following: Consulting/speaker honoraria from Abbott Vascular, American Heart Association (Associate Editor, Circulation), Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, and Medtronic. Research support from Siemens, and Regeneron, Shareholder: MHI Ventures. Board of Trustees: Society of Cardiovascular Angiography and Interventions.

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Bagai, J., Brilakis, E.S. Update in the Management of Acute Coronary Syndrome Patients with Cardiogenic Shock. Curr Cardiol Rep 21, 17 (2019). https://doi.org/10.1007/s11886-019-1102-3

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