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Acute coronary syndromes
Management of cardiogenic shock complicating acute coronary syndromes
  1. Dushen Tharmaratnam1,
  2. Jim Nolan2,
  3. Ajay Jain1
  1. 1Department of Cardiology, London Chest Hospital, London, UK
  2. 2Department of Cardiology, University Hospital of North Staffordshire, Stoke-on-Trent, UK
  1. Correspondence to Dr Ajay Jain, Department of Cardiology, Barts Health NHS Trust, London Chest Hospital, Bonner Road, London E2 9JX, UK; ajay.jain{at}bartshealth.nhs.uk

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Cardiogenic shock (CS) remains the leading cause of mortality in patients hospitalised with acute myocardial infarction (AMI).1 Recent guidelines supporting a strategy of early revascularisation (ERV) have led to some improvements in the outcomes of this patient subset.2 ,3 However, despite significant improvements in treatment, the mortality rate associated with CS in the context of AMI remains high, especially in those patients who present to hospital late or have delayed coronary reperfusion. This article aims to review the available data relating to this important condition, and provide guidelines for current best practice in the management of CS.

Definition

CS is a condition characterised by inadequate tissue perfusion, usually in the setting of AMI. There have been many definitions applied to the diagnosis of CS, but the most uniformly accepted clinical definition of CS is decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Haemodynamic criteria are also important in the diagnosis of CS. The most important are sustained hypotension (systolic blood pressure (BP) <90 mm Hg for at least 1 h) and a reduced cardiac index (<2.2 l/min/m2) in the presence of elevated pulmonary capillary wedge pressure (PCWP) >18 mm Hg.w1

Incidence

There are inconsistencies in the reported incidence of CS. These inconsistencies may be largely related to the varying definitions that have been adopted to describe this clinical entity. Additionally, the true incidence of CS complicating AMI may be underestimated since a proportion of patients will die before arrival at hospital. Given these limitations, the historically reported incidence of CS complicating AMI is between 5–8%.w2 w3 There is contemporary evidence that the rate of CS complicating ST elevation myocardial infarction (STEMI) has seen a small decrease in incidence,4 which in part may be due to the more rapid diagnosis and better hospital based treatment …

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