Update in the Management of Acute Coronary Syndrome Patients with Cardiogenic Shock
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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.
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.
KeywordsCardiogenic shock Acute coronary syndrome Acute myocardial infarction Mechanical circulatory support Update
Acute coronary syndrome
Acute myocardial infarction complicated with cardiogenic shock
Coronary artery disease
Cardiac power output
Chronic total occlusion
Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock
Catheter-based ventricular assist device
Central venous pressure
Extracorporeal cardiopulmonary resuscitation
Intra-aortic balloon pump
- IABP-SHOCK II
Intra-aortic Balloon Pump in Cardiogenic Shock II
Impella versus IABP Reduces mortality in STEMI patients treated with primary PCI in severe cardiogenic SHOCK
Mechanical circulatory support
Acute myocardial infarction
Pulmonary Artery Pulsatility Index
Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome
Systolic blood pressure
Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock
ST segment elevation acute myocardial infarction
Veno-arterial extracorporeal membrane oxygenation
Compliance with Ethical Standards
Conflict of Interest
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.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 1.Harjola VP, Lassus J, Sionis A, et al. CardShock Study Investigators; GREAT Network. Clinical picture and risk prediction of short-term mortality in cardiogenic shock [published correction appears in Eur J heart fail. 2015;17:984]. Eur J Heart Fail. 2015;17:501–9. https://doi.org/10.1002/ejhf.260.
- 2.Wayangankar SA, Bangalore S, McCoy LA, et al. Temporal trends and outcomes of patients undergoing percutaneous coronary interventions for cardiogenic shock in the setting of acute myocardial infarction: a report from the CathPCI Registry. JACC Cardiovasc Interv. 2016;9:341–51. https://doi.org/10.1016/j.jcin.2015.10.039.
- 6.Nguyen HL, Yarzebski J, Lessard D, et al. Ten-year (2001-2011) trends in the incidence rates and short-term outcomes of early versus late onset cardiogenic shock after hospitalization for acute myocardial infarction. J Am Heart Assoc. 2017;6(6).Google Scholar
- 8.•• van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2017;136(16):e232–68 Comprehensive summary of AMICS management including a proposed regional system of care for AMICS. PubMedGoogle Scholar
- 9.Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD, 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;341:625–34. https://doi.org/10.1056/NEJM199908263410901.CrossRefPubMedGoogle Scholar
- 12.•• Ouweneel DM, Eriksen E, Sjauw KD, et al. Percutaneous mechanical circulatory support versus intra-aortic balloon pump in cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2017;69(3):278–87 Randomized-controlled trial showing no difference in outcomes with Impella vs. and IABP in AMICS patients. CrossRefGoogle Scholar
- 16.Dzavik V, Sleeper LA, Cocke TP, Moscucci M, Saucedo J, Hosat S, et al. Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry. Eur Heart J. 2003;24:828–37.CrossRefGoogle Scholar
- 18.O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force On Practice Guidelines. Circulation. 2013;127(4):e362–425. https://doi.org/10.1161/CIR.0b013e3182742cf6.CrossRefPubMedGoogle Scholar
- 19.Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (radial versus femoral randomized investigation in ST-elevation acute coronary syndrome) study. J Am Coll Cardiol. 2012;60(24):2481–9.CrossRefGoogle Scholar
- 20.Roule V, Lemaitre A, Sabatier R, Lognoné T, Dahdouh Z, Berger L, et al. Transradial versus transfemoral approach for percutaneous coronary intervention in cardiogenic shock: a radial-first centre experience and meta-analysis of published studies. Arch Cardiovasc Dis. 2015;108(11):563–75.CrossRefGoogle Scholar
- 21.Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon pump in cardiogenic shock II (IABP-SHOCK II) trial investigators. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12-month results of a randomized open-label trial. Lancet. 2013;382(9905):1638–45.CrossRefGoogle Scholar
- 22.•• Neumann FJ, Sousa-Uva M, Ahlsson A, et al. ESC Scientific Document Group. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2018. https://doi.org/10.1093/eurheartj/ehy394 Latest European Society of Cardiology/European Association of Cardio-Thoracic Surgery guidelines that recommend performing culprit-only PCI and avoiding routine use of IABP in AMICS.
- 25.•• Mandawat A, Rao SV. Percutaneous mechanical circulatory support devices in cardiogenic shock. Circ Cardiovasc Interv. 2017;10(5):e004337. https://doi.org/10.1161/CIRCINTERVENTIONS.116.004337 Excellent summary on MCS therapy based on shock hemodynamics. CrossRefPubMedPubMedCentralGoogle Scholar
- 26.•• O'Neill WW, Grines C, Schreiber T, et al. Analysis of outcomes for 15,259 US patients with acute myocardial infarction cardiogenic shock (AMICS) supported with the Impella device. Am Heart J. 2018;202:33–8 Large study from a national quality improvement database between 2009-2016 showing the pre-PCI insertion of Impella in AMICS was associated with lower mortality. CrossRefGoogle Scholar
- 28.•• Basir MB, Schreiber T, Dixon S, et al. Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: the Detroit cardiogenic shock initiative. Catheter Cardiovasc Interv. 2018;91(3):454–61 Prospective multicenter study reporting improved outcomes after implementation of a systematic protocol for managing AMICS patients. CrossRefGoogle Scholar
- 29.Kapur NK et al. The door to unload (DTU) safety and feasibility pilot trial. Presented at the 2018 American Heart Association Late Breaking Clinical Science.Google Scholar
- 30.Smith L, Peters A, Mazimba S, Ragosta M, Taylor AM. Outcomes of patients with cardiogenic shock treated with TandemHeart (®) percutaneous ventricular assist device: importance of support indication and definitive therapies as determinants of prognosis. Catheter Cardiovasc Interv. 2018;92:1173–81. https://doi.org/10.1002/ccd.27650.CrossRefPubMedGoogle Scholar
- 31.Huang CC, Hsu JC, Wu YW, et al. Implementation of extracorporeal membrane oxygenation before primary percutaneous coronary intervention may improve the survival of patients with ST-segment elevation myocardial infarction and refractory cardiogenic shock. Int J Cardiol. 2018;269:45–50.CrossRefGoogle Scholar
- 32.Kagawa E, Dote K, Kato M, Sasaki S, Nakano Y, Kajikawa M, et al. Should we emergently revascularize occluded coronaries for cardiac arrest? Rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation. 2012;126(13):1605–13.CrossRefGoogle Scholar
- 33.Cho S, Lee W, Lim SH, Kang TS. Relationship between clinical outcomes and cardiopulmonary resuscitation time in patients with acute myocardial infarction treated by extracorporeal membrane oxygenation-assisted primary percutaneous coronary intervention. Korean Circ J. 2018;48(8):705–15.CrossRefGoogle Scholar
- 34.Chen YS, Lin JW, Yu HY, Ko WJ, Jerng JS, Chang WT, et al. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008;372(9638):554–61.CrossRefGoogle Scholar
- 35.•• Atkinson TM, Ohman EM, O'Neill WW, Rab T, Cigarroa JE. Interventional Scientific Council of The American College of Cardiology. A practical approach to mechanical circulatory support in patients undergoing percutaneous coronary intervention: an interventional perspective. JACC Cardiovasc Interv. 2016;9(9):871–83. https://doi.org/10.1016/j.jcin.2016.02.046 Comprehensive summary of MCS selection. CrossRefPubMedGoogle Scholar
- 37.Lala A, Guo Y, Xu J, Esposito M, Morine K, Karas R, et al. Right ventricular dysfunction in acute myocardial infarction complicated by cardiogenic shock: a hemodynamic analysis of the should we emergently revascularize occluded coronaries for cardiogenic SHOCK (SHOCK) trial and registry. J Card Fail. 2018;24(3):148–56. https://doi.org/10.1016/j.cardfail.2017.10.009.CrossRefPubMedGoogle Scholar
- 38.•• Kapur NK, Esposito ML, Bader Y, et al. Mechanical circulatory support devices for acute right ventricular failure. Circulation. 2017;136(3):314–26. https://doi.org/10.1161/CIRCULATIONAHA.116.025290 Comprehensive summary of hemodynamic variables and MCS strategies for shock due to right ventricular failure. CrossRefPubMedGoogle Scholar
- 42.Mahmoud AN, Elgendy IY, Mojadidi MK, et al. Prevalence, causes, and predictors of 30-day readmissions following hospitalization with acute myocardial infarction complicated by cardiogenic shock: findings from the 2013-2014 National Readmissions Database. J Am Heart Assoc. 2018;23:7(6).Google Scholar