Cardiogenic shock following myocardial infarction

Cardiogenic shock is a syndrome caused by a significant reduction in cardiac output resulting in hypotension with signs of impaired perfusion, including oliguria. Even with aggressive supportive therapy, mortality in patients with cardiogenic shock is high.

An echocardiogram should be obtained, but this should not delay coronary angiography and reperfusion. Early coronary revascularisation should be performed, and additional haemodynamic support considered. It may be necessary to transfer the patient to a tertiary site where more advanced cardiac support is available. Haemodynamic support can include inotropic support; for example:

Ideally, give adrenaline (epinephrine) through a central venous catheter; the infusion may be started in a large antecubital vein while central venous access is organised. Alternative inotropic drugs may be used; seek specialist advice.

Mechanical haemodynamic support includes intra-aortic balloon pump (IABP), left ventricular-assist devices (LVADs) and extracorporeal membrane oxygenation (ECMO). Randomised trials of IABP use in myocardial infarction–related cardiogenic shock have failed to show a survival benefit; routine use is not indicatedThiele, 2012. Evidence for other haemodynamic support devices is limitedO'Neill, 2012Ouweneel, 2017.

Consider the possibility of cardiac rupture if there is sudden clinical deterioration. Immediate confirmation of cardiac tamponade by echocardiography, with urgent pericardiocentesis, can be lifesaving.