Updates in the Management of Cardiogenic Shock in Acute Coronary Syndrome

  • Maurizio Ferrario
  • Tiziana Spezzano
  • Marco Ferlini
  • Antonio Sciortino
  • Fabrizio Gazzoli
  • Antonino M. GrandeEmail author


Cardiogenic shock is a complex clinical status characterized by a progressive multi-organ dysfunction determined by the failure of the heart to deliver an adequate amount of blood to the tissues. It complicates approximately 5–10% of cases with acute myocardial infarction. Ischemia due to decreased coronary perfusion leads to muscle hypoxia and necrosis which compromises myocardial contractility. This leads to decreased cardiac output and a subsequent drop in the arterial blood pressure. Coronary revascularization should be performed as soon as possible after AMI and shock onset. After the SHOCK trial, we have witnessed the reduction in the incidence of cardiogenic shock due to early revascularization. Although the primary endpoint, all-cause mortality at 30 days, did not differ between the initial medical stabilization and early revascularization group, there was a significant decrease in mortality after 1 and 6 years in patients assigned to early revascularization. In this chapter incidence, pathophysiology, etiology, clinical symptoms, and therapeutic options in cardiogenic shock are discussed. Two clinical cases and a case scenario allow the reader to get through the content.


Cardiogenic shock Acute coronary syndrome Advanced cardiovascular life support (ACLS) Extracorporeal membrane oxygenator (ECMO), Veno arterial Extracorporeal membrane oxygenator (VA-ECMO), Veno venous Extracorporeal membrane oxygenator (VV-ECMO) Left ventricular assist device (LVAD) Percutaneous coronary intervention (PCI) Intra-aortic balloon pump (IABP) Coronary bypass 


  1. 1.
    Hollenberg SM, Kavinsky CJ, Parrillo JE. Cardiogenic shock. Ann Intern Med. 1999;131:47–59.CrossRefGoogle Scholar
  2. 2.
    Babaev A, Frederick PD, Pasta DJ, et al. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA. 2005;294:448–54.CrossRefGoogle Scholar
  3. 3.
    Khalid L, Dhakam SH. A review of cardiogenic shock in acute myocardial infarction. Curr Cardiol Rev. 2008;4(1):34–40.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Goldberg RJ, Gore JM, Alpert JS, et al. Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. N Engl J Med. 1991;325:1117–22.CrossRefGoogle Scholar
  5. 5.
    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;26:668–74.CrossRefGoogle Scholar
  6. 6.
    Ponikowski P, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–200. Scholar
  7. 7.
    Hochman JS, et al. Early revascularisation in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med. 1999;341:625–34.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Hochman JS, Sleeper LA, White HD, et al. One-year survival following early revascularization for cardiogenic shock. JAMA. 2001;285:190–2.CrossRefGoogle Scholar
  9. 9.
    Van Herck JL, Claeys MJ, De Paep R, Van Herck PL, Vrints CJ, Jorens PG. Management of cardiogenic shock complicating acute myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2015;4(3):278–97.CrossRefGoogle Scholar
  10. 10.
    Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33:2569–619.CrossRefGoogle Scholar
  11. 11.
    Hussain F, Philipp RK, Ducas RA, et al. The ability to achieve complete revascularization is associated with improved in-hospital survival in cardiogenic shock due to myocardial infarction: manitoba cardiogenic shock registry investigators. Catheter Cardiovasc Interv. 2011;78:540–8.CrossRefGoogle Scholar
  12. 12.
    David S, Wald MD, et al. Randomized trial of preventive angioplasty in myocardial infarction for the PRAMI investigators. N Engl J Med. 2013;369:1115–23.CrossRefGoogle Scholar
  13. 13.
    Engstrøm T, et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386(9994):665–71.CrossRefGoogle Scholar
  14. 14.
    Birnbaum Y, Fishbein MC, Blance C, Siegal R. Ventricular septal rupture after acute myocardial infarction. N Engl J Med. 2002;347:1426–32.CrossRefGoogle Scholar
  15. 15.
    Moreyra AE, et al. Trends in incidence and mortality rates of ventricular septal rupture during acute myocardial infarction. Am J Cardiol. 2010;106:1095–100.CrossRefGoogle Scholar
  16. 16.
    Westaby S, Kharbanda R, Banning AP. Cardiogenic shock in ACS. Part 1: prediction, presentation and medical therapy. Nat Rev Cardiol. 2012;9:158–71. Published online 20 December 2011.CrossRefGoogle Scholar
  17. 17.
    Tavakoli R, et al. Results of surgery for irreversible moderate to severe mitral valve regurgitation secondary to myocardial infarction. Eur J Cardiothorac Surg. 2002;21:818–24.CrossRefGoogle Scholar
  18. 18.
    Sidebotham D. Troubleshooting adult ECMO. J Extra Corpor Technol. 2011;43:P27–32.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Maurizio Ferrario
    • 1
  • Tiziana Spezzano
    • 1
  • Marco Ferlini
    • 1
  • Antonio Sciortino
    • 2
  • Fabrizio Gazzoli
    • 2
  • Antonino M. Grande
    • 2
    Email author
  1. 1.CardiologyIRCCS Fondazione Policlinico San MatteoPaviaItaly
  2. 2.Department of Cardiac SurgeryIRCCS Fondazione Policlinico San MatteoPaviaItaly

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