Optional statement
Cardiogenic shock, a devastating consequence of acute myocardial infarction, is associated with extremely high mortality. Treatment strategies should focus on prompt reperfusion and hemodynamic support. The primary approach for therapy is emergent angiography and revascularization using percutaneous coronary intervention or coronary artery bypass surgery, with the assistance of intra-aortic balloon pump counterpulsation. Several adjunctive pharmacologic agents, particularly inotropic drugs and vasopressors, are also helpful for hemodynamic support. However, these agents have not been shown to provide a survival benefit, and their use is primarily based on clinical experience. Since our last publication, several important advances have been made in the understanding and treatment of cardiogenic shock. Recent evidence suggests that a systemic inflammatory response, including the upregulation of inducible nitric oxide synthase, complement activation, and an inflammatory cytokine cascade, play a role in the development of cardiogenic shock. Newer therapeutic strategies, including C5 inhibitors and nitric oxide synthase inhibitors, are being combined with traditional strategies, such as inotropic agents, vasopressors, and circulatory assist, to treat cardiogenic shock.
Similar content being viewed by others
References and Recommended Reading
Holmes DR Jr, Bates ER, Kleiman NS, et al.: Contemporary reperfusion therapy for cardiogenic shock: the GUSTO-I trial experience. The GUSTO-I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. J Am Coll Cardiol 1995, 26:668–674.
Hochman JS, Sleeper LA, Webb JG, et al.: Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock? N Engl J Med 1999, 341:625–634. The SHOCK trial is the only large randomized trial of early revascularization compared with medical therapy in cardiogenic shock. The 30-day results did not achieve statistical significance, but the 6-month data suggest the superiority of early revascularization in patients less than 75 years old.
Killip T III, Kimball JT: Treatment of myocardial infarction in a coronary care unit. A two-year experience with 250 patients. Am J Cardiol 1967, 20:457–464.
Babaev A, Frederick PD, Pasta D, et al.: Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA 2005, 294:448–454.
Theroux P, Armstrong PW, Mahaffey KW, et al.: Prognostic significance of blood markers of inflammation in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty and effects of pexelizumab, a C5 inhibitor: a substudy of the COMMA trial. Eur Heart J 2005, 26:1964–1970.
Potapov EV, Hennig F, Wagner FD, et al.: Natriuretic peptides and E-selectin as predictors of acute deterioration in patients with inotrope-dependent heart failure. Eur J Cardiothorac Surg 2005, 27:899–905.
Webb JG, Sleeper LA, Buller CE, et al.: Implications of the timing of onset of cardiogenic shock after acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock? J Am Coll Cardiol 2000, 36(3 suppl A):1084–1090.
Page DL, Caulfield JB, Kastor JA, et al.: Myocardial changes associated with cardiogenic shock. N Engl J Med 1971, 285:133–137.
Alonso DR, Scheidt S, Post M, Killip T: Pathophysiology of cardiogenic shock Quantification of myocardial necrosis, clinical, pathologic and electrocardiographic correlations. Circulation 1973, 48:588–596.
Holmes DR Jr, Berger PB, Hochman JS, et al.: Cardiogenic shock in patients with acute ischemic syndromes with and without ST-segment elevation. Circulation 1999, 100:2067–2073.
Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group [no authors listed]. Lancet 1988, 2:349–360.
Kohsaka S, Menon V, Lowe AM, et al.: Systemic inflammatory response syndrome after acute myocardial infarction complicated by cardiogenic shock. Arch Intern Med 2005, 165:1643–1650.
Hochman JS: Cardiogenic shock complicating acute myocardial infarction: expanding the paradigm. Circulation 2003, 107:2998–3002.
Smart N, Mojet M, Latchman DS, et al.: IL-6 induces PI 3-kinase and nitric oxide-dependent protection and preserves mitochondrial function in cardiomyocytes. Cardiovasc Res 2005, Oct 7; [Epub ahead of print].
Lehmann A, Boldt J: New pharmacological approaches for the perioperative treatment of ischemic cardiogenic shock. J Cardiothorac Vasc Anesth 2005, 19:97–108.
Cohen M, Kelly R, Kong D, et al.: Pulmonary artery catheterization in acute coronary syndromes: insights from the GUSTO IIb and GUSTO III trials. Am J Med 2005, 118:482–488.
Fincke R, Hochman JS, Lowe A, et al.: Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry. J Am Coll Cardiol 2004, 44:340–308.
Sanborn T, Sleeper L, Webb J: Correlates of one year survival in patients with cardiogenic shock complicating acute myocardial infarction: angiographic findings from the SHOCK trial. J Am Coll Cardiol 2003, 42:1373–1379.
Ryan TJ, Anderson JL, Antman EM, et al.: ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1996, 28:1328–1428.
Tuttle RR, Mills J: Dobutamine: development of a new catecholamine to selectively increase cardiac contractility. Circ Res 1975, 36:185–196.
Kirk ES, LeJemtel TH, Nelson GR, Sonnenblick EH: Mechanisms of beneficial effects of vasodilators and inotropic stimulation in the experimental failing ischemic heart. Am J Med 1978, 65:189–196.
Gage J, Rutman H, Lucido D, LeJemtel TH: Additive effects of dobutamine and amrinone on myocardial contractility and ventricular performance in patients with severe heart failure. Circulation 1986, 74:367–373.
Jugdutt BI, Warnica JW: Intravenous nitroglycerin therapy to limit myocardial infarct size, expansion, and complications. Effect of timing, dosage, and infarct location. Circulation 1988, 78:906–919.
Chiariello M, Gold HK, Leinbach RC, et al.: Comparison between the effects of nitroprusside and nitroglycerin on ischemic injury during acute myocardial infarction. Circulation 1976, 54:766–773.
Unger T: The role of the renin-angiotensin system in the development of cardiovascular disease. Am J Cardiol 2002, 89:3A-9A.
Swedberg K, Held P, Kjekshus J, et al.: Effects of the early administration of enalapril on mortality in patients with acute myocardial infarction. Results of the Cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II). N Engl J Med 1992, 327:678–684.
Pfeffer MA, Braunwald E, Moye LA, et al.: Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med 1992, 327:669–677.
GISSI-3: effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction. Gruppo Italiano per lo Studio della Sopravvivenza nell’infarto Miocardico [no authors listed]. Lancet 1994, 343:1115–1122.
ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58,050 patients with suspected acute myocardial infarction. ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group [no authors listed]. Lancet 1995, 345:669–685.
Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators [no authors listed]. Lancet 1993, 342:821–828.
The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group [no authors listed]. N Engl J Med 1997, 336:525–533.
Hasdai D, Harrington RA, Hochman JS, et al.: Platelet glycoprotein IIb/IIIa blockade and outcome of cardiogenic shock complicating acute coronary syndromes without persistent ST-segment elevation. J Am Coll Cardiol 2000, 36:685–692. This substudy of the PURSUIT trial suggests that the use of eptifibatide is independently associated with a reduced mortality among patients with acute coronary syndromes who develop cardiogenic shock.
Topol EJ: Reperfusion therapy for acute myocardial infarction with fibrinolytic therapy or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition: the GUSTO V randomised trial. Lancet 2001, 357:1905–1914.
Giri S, Mitchel J, Kiernan F, et al.: Adjunctive use of abciximab improves clinical outcomes in acute myocardial infarction patients presenting with cardiogenic shock [abstract]. Paper presented at the American College of Cardiology 48th Annual Scientific Sessions. New Orleans, LA; March 7–10, 1999.
Geppert A, Huber K: Inflammation and cardiovascular diseases: lessons that can be learned for the patient with cardiogenic shock in the intensive care unit. Curr Opin Crit Care 2004, 10:347–353.
Cotter G, Moshkovitz Y, Kaluski E, et al.: The role of cardiac power and systemic vascular resistance in the pathophysiology and diagnosis of patients with acute congestive heart failure. Eur J Heart 2003, 5:443–451.
Cotter G, Kaluski E, Milo O, et al.: LINCS: L-NAME (a NO synthase inhibitor) in the treatment of refractory cardiogenic shock: a prospective randomized study. Eur Heart J 2003, 24:1279–1281.
Opie LH: Glucose and the metabolism of ischaemic myocardium. Lancet 1995, 345:1520–1521.
Corbucci GG, Loche F: L-carnitine in cardiogenic shock therapy: pharmacodynamic aspects and clinical data. Int J Clin Pharmacol Res 1993, 13:87–91.
Diaz R, Paolasso EA, Piegas LS, et al.: Metabolic modulation of acute myocardial infarction. The ECLA (Estudios Cardiologicos Latinoamerica) Collaborative Group. Circulation 1998, 98:2227–2234.
Hasdai D, Holmes DR Jr, Topol EJ, et al.: Frequency and clinical outcome of cardiogenic shock during acute myocardial infarction among patients receiving reteplase or alteplase. Results from GUSTO-III. Global Use of Strategies to Open Occluded Coronary Arteries. Eur Heart J 1999, 20:128–135.
Menon V, Hochman JS, Stebbins A, et al.: Lack of progress in cardiogenic shock: lessons from the GUSTO trials. Eur Heart J 2000, 21:1928–1936.
Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI) [no authors listed]. Lancet 1986, 1:397–402.
Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group [no authors listed]. Lancet 1994, 343:311–322.
Garber PJ, Gu S, Ducas J, et al.: An increase in low aortic pressure increases coronary artery flow and coronary thrombolysis induced by intravenous administration of recombinant tissue plasminogen activator. J Crit Care 1995, 10:1–6.
Prewitt RM, Gu S, Schick U, Ducas J: Intra-aortic balloon counterpulsation enhances coronary thrombolysis induced by intravenous administration of a thrombolytic agent. J Am Coll Cardiol 1994, 23:794–798.
Kovack PJ, Rasak MA, Bates ER, et al.: Thrombolysis plus aortic counterpulsation: improved survival in patients who present to community hospitals with cardiogenic shock. J Am Coll Cardiol 1997, 29:1454–1458.
Barron HV, Every NR, Parsons LS, et al.: The use of intraaortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: data from the National Registry of Myocardial Infarction 2. Am Heart J 2001, 141:933–939.
Brener SJ, Lincoff MA, Bates ER, et al.: The relationship between baseline risk and mortality in ST-elevation acute myocardial infarction treated with pharmacological reperfusion: insights from the Global Utilization of Strategies To open Occluded arteries (GUSTO) V trial. Am Heart J 2005, 150:89–93.
Bueno H, Martinez-Selles M, Perez-David E, et al.: Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction. Eur Heart J 2005, 26:1705–1711.
Berger PB, Holmes DR Jr, Stebbins AL, et al.: Impact of an aggressive invasive catheterization and revascularization strategy on mortality in patients with cardiogenic shock in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial. An observational study. Circulation 1997, 96:122–127.
Bolooki H: Emergency cardiac procedures in patients in cardiogenic shock due to complications of coronary artery disease. Circulation 1989, 79(6 Pt 2):I137-I148.
Guyton RA, Arcidi JM Jr, Langford DA, et al.: Emergency coronary bypass for cardiogenic shock. Circulation 1987, 76(5 Pt 2):V22-V27.
Hibbard MD, Holmes DR Jr, Bailey KR, et al.: Percutaneous transluminal coronary angioplasty in patients with cardiogenic shock. J Am Coll Cardiol 1992, 19:639–646.
Lee L, Bates ER, Pitt B, et al.: Percutaneous transluminal coronary angioplasty improves survival in acute myocardial infarction complicated by cardiogenic shock. Circulation 1988, 78:1345–1351.
Moosvi AR, Khaja F, Villanueva L, et al.: Early revascularization improves survival in cardiogenic shock complicating acute myocardial infarction. J Am Coll Cardiol 1992, 19:907–914.
Yamamoto H, Hayashi Y, Oka Y, et al.: Efficacy of percutaneous transluminal coronary angioplasty in patients with acute myocardial infarction complicated by cardiogenic shock. Jpn Circ J 1992, 56:815–821.
Antoniucci D, Valenti R, Santoro GM, et al.: Systematic direct angioplasty and stent-supported direct angioplasty therapy for cardiogenic shock complicating acute myocardial infarction: in-hospital and long-term survival. J Am Coll Cardiol 1998, 31:294–300.
Moscucci M, Bates ER: Cardiogenic shock. Cardiol Clin 1995, 13:391–406.
Hochman JS, Sleeper LA, White HD, et al.: One-year survival following early revascularization for cardiogenic shock. JAMA 2001, 285:190–192. The extended (1-year) follow-up results of the SHOCK trial show a persistent survival benefit associated with early revascularization in patients with cardiogenic shock.
Vlassov GP, Deyneka CS, Travine NO, et al.: Acute myocardial infarction: OPCAB is an alternative approach for treatment. Heart Surg Forum 2001, 4:147–150.
Parrino PE, Kron IL: The role of left ventricular reconstruction for cardiogenic shock. Semin Thorac Cardiovasc Surg 2001, 13:476–479.
Ryan TJ, Antman EM, Brooks NH, et al.: 1999 update: ACC/ AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1999, 34:890–911. A recent update of the ACC and AHA recommendations for the treatment of cardiogenic shock, which incorporates the findings of the SHOCK trial. Early revascularization is upgraded to a Class I recommendation.
Hasdai D: Should we aggressively treat elderly patients with cardiogenic shock? Am Heart J 2005, 149:962–963.
Antman EM, Anbe DT, Wayne P, et al.: ACC/AHA guidelines for management of patients with ST-elevation myocardial infarction-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines(writing committee to revise the 1999 guidelines for management of patients with acute myocardial infarction). J Am Coll Cardiol 2004, 44:671–719.
Nanas JN, Moulopoulos SD: Counterpulsation: historical background, technical improvements, hemodynamic and metabolic effects. Cardiology 1994, 84:156–167.
Ohman EM, George BS, White CJ, et al.: Use of aortic counterpulsation to improve sustained coronary artery patency during acute myocardial infarction. Results of a randomized trial. The Randomized IABP Study Group. Circulation 1994, 90:792–799.
Sanborn TA, Sleeper LA, Bates ER, et al.: Impact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock? J Am Coll Cardiol 2000, 36(3 suppl A):1123–1129.
Chen EW, Canto JG, Parsons LS, et al.: Relation between hospital intra-aortic balloon counterpulsation volume and mortality in acute myocardial infarction complicated by cardiogenic shock. Circulation 2003, 108:951–957.
Ohman EM, Nanas J, Stomel RJ, et al.: Thrombolysis and counterpulsation to improve survival in myocardial infarction complicated by hypotension and suspected cardiogenic shock or heart failure: results of the TACTICS Trial. J Thromb Thrombolysis 2005, 19:33–39.
Elahi MM, Chetty GK, Kirke R, et al.: Complications related to intra-aortic balloon pump in cardiac surgery: a decade later. Eur J Vasc Endovasc Surg 2005, 29:591–594.
Pagani FD, Lynch W, Swaniker F, et al.: Extracorporeal life support to left ventricular assist device bridge to heart transplant: a strategy to optimize survival and resource utilization. Circulation 1999, 100(19 suppl):II206-II210.
Smalling RW: Transvalvular left ventricular assistance in acute myocardial infarction with cardiogenic shock and high risk angioplasty: experimental and clinical results with the Hemopump. J Interv Cardiol 1995, 8:265–273.
Sweeney MS: The Hemopump in 1997: a clinical, political, and marketing evolution. Ann Thorac Surg 1999, 68:761–763.
Thiele H, Lauer B, Hambrecht R, et al.: Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance. Circulation 2001, 104:2917–2922.
Thiele H, Sick P, Boudriot E, et al.: Randomized comparison of intra-aortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. Eur Heart J 2005, 26:1276–1283.
Fonarow G, Wright SR, Spencer FA, et al.: Effect of statin use within the first 24 hours of admission for acute myocardial infarction on early morbidity and mortality. Am J Cardiol 2005, 96:611–616.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Ellis, T.C., Lev, E., Yazbek, N.F. et al. Therapeutic strategies for cardiogenic shock, 2006. Curr Treat Options Cardio Med 8, 79–94 (2006). https://doi.org/10.1007/s11936-006-0028-4
Issue Date:
DOI: https://doi.org/10.1007/s11936-006-0028-4