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

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. 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.

Keywords: Acute coronary syndrome; Acute myocardial infarction; Cardiogenic shock; Mechanical circulatory support; Update.