Ischaemic cardiogenic shock

Cardiogenic shock is an important complication of myocardial infarction/ischaemia with a mortality of approximately 50%. Pivotal to treatment is prompt diagnosis with emergency revascularization, as delaying revascularization for medical stabilization is associated with a significantly higher mortality. Early intubation and ventilation are recommended, together with mechanical circulatory support using intra-aortic balloon counterpulsation. The use of inotropic agents is potentially hazardous as they generally increase myocardial oxygen demand, thereby exacerbating ischaemia. When required, inotropes should be administered as early as possible and reduced/stopped as soon as adequate organ perfusion is restored. The inotrope/vasopressor combination used should be titrated according to the patient’s haemodynamics, guided by clinical examination, echocardiography and cardiac output monitoring. Mechanical complications are increasingly rare in the post-revascularization era; however, they remain potentially lethal. Prompt diagnosis using echocardiography is key, and early discussion with surgical colleagues is required. Although prognosis in cardiogenic shock is poor, our increasing understanding of the immune/inflammatory nature of the condition may result in the development of pharmacological agents which limit the ongoing myocardial/organ damage. This, together with safer and more effective mechanisms of advanced circulatory support may improve outcomes in cardiogenic shock in the future.