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Cardiogenic Shock After Acute Myocardial InfarctionA Review

Educational Objective
To review the clinical management of patients with cardiogenic shock following acute myocardial infarction.
1 Credit CME
Abstract

Importance  Cardiogenic shock affects between 40 000 and 50 000 people in the US per year and is the leading cause of in-hospital mortality following acute myocardial infarction.

Observations  Thirty-day mortality for patients with cardiogenic shock due to myocardial infarction is approximately 40%, and 1-year mortality approaches 50%. Immediate revascularization of the infarct-related coronary artery remains the only treatment for cardiogenic shock associated with acute myocardial infarction supported by randomized clinical trials. The Percutaneous Coronary Intervention Strategies with Acute Myocardial Infarction and Cardiogenic Shock (CULPRIT-SHOCK) clinical trial demonstrated a reduction in the primary outcome of 30-day death or kidney replacement therapy; 158 of 344 patients (45.9%) in the culprit lesion revascularization–only group compared with 189 of 341 patients (55.4%) in the multivessel percutaneous coronary intervention group (relative risk, 0.83 [95% CI, 0.71-0.96]; P = .01). Despite a lack of randomized trials demonstrating benefit, percutaneous mechanical circulatory support devices are frequently used to manage cardiogenic shock following acute myocardial infarction.

Conclusions and Relevance  Cardiogenic shock occurs in up to 10% of patients immediately following acute myocardial infarction and is associated with mortality rates of nearly 40% at 30 days and 50% at 1 year. Current evidence and clinical practice guidelines support immediate revascularization of the infarct-related coronary artery as the primary therapy for cardiogenic shock following acute myocardial infarction.

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Article Information

Corresponding Author: Sunil V. Rao, MD, Duke University Health System, 508 Fulton St, 111A, Durham, NC 27705 (sunil.rao@duke.edu).

Accepted for Publication: September 27, 2021.

Correction: This article was updated on November 12, 2021, to correct the term “percutaneous medical circulatory” to be “percutaneous mechanical circulatory” and to fix the directionality of a statement about survival rates in the Support Devices section.

Author Contributions: Drs Samsky and Rao had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Samsky.

Drafting of the manuscript: Samsky, Proudfoot.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Samsky.

Administrative, technical, or material support: Samsky.

Supervision: Samsky, Proudfoot, Rao.

Conflict of Interest Disclosures: Dr Morrow reported receiving research grants to Brigham and Women’s Hospital from Abbott Laboratories, Amgen, Anthos, Arca Biopharma, AstraZeneca, Bayer Healthcare, Daiichi Sankyo, Eisai, and Merck; grants from Novartis, Pfizer, Quark, Regeneron, Roche Diagnostics, and Siemens; personal fees for consulting unrelated to shock from Bayer Healthcare, Merck, Novartis, and Roche Diagnostics; and personal fees from InCarda for data and safety monitoring board membership outside the submitted work and being a member of the TIMI Study Group, which has received institutional research grant support through Brigham and Women's Hospital from Abbott, Amgen, Anthos Therapeutics, AstraZeneca, Bayer HealthCare Pharmaceuticals, Daiichi-Sankyo, Eisai, Intarcia, MedImmune, Merck, Novartis, Pfizer, Quark Pharmaceuticals, Regeneron Pharmaceuticals, Roche, Siemens Healthcare Diagnostics, The Medicines Company, and Zora Biosciences. Dr Proudfoot reported receiving grants from Abbott Vascular during the conduct of the study. Dr Rao reported receiving institutional research funding from Bayer and the National Heart, Lung, and Blood Institute outside the submitted work. No other disclosures were reported.

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