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MANAGEMENT OF CARDIOGENIC SHOCK COMPLICATING ACUTE MYOCARDIAL INFARCTION
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  1. Venu Menon1,
  2. Judith S Hochman2
  1. 1Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA
  2. 2Division of Cardiology, St Luke’s-Roosevelt Hospital Center, Columbia College of Physicians & Surgeons, New York, USA
  1. Correspondence:
    Judith S Hochman MD, Columbia University, St Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025, USA;
    jsh4{at}columbia.edu

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The incidence of cardiogenic shock in community studies has not decreased significantly over time. Despite decreasing mortality rates associated with increasing utilisation of revascularisation, shock remains the leading cause of death for patients hospitalised with acute myocardial infarction (MI). Although shock often develops early after MI onset, it is typically not diagnosed on hospital presentation. Failure to recognise early haemodynamic compromise and the increased early use of hypotension inducing treatments may explain this observation.

Recently, a randomised trial has demonstrated that early revascularisation reduces six and 12 month mortality.1,2 The current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend the adoption of an early revascularisation strategy for patients < 75 years of age with cardiogenic shock.3 In this article, we review the incidence, aetiology, prevention, and recognition of shock, as well as its management.

▸ INCIDENCE

The extent of myocardial salvage from reperfusion treatment decreases exponentially with time to re-establishing coronary flow. Unfortunately, there has been little progress in reducing time to hospital presentation over the past decade,4 and this perhaps accounts for the stagnant incidence of cardiogenic shock in community studies (7.1%).5 Cardiogenic shock also complicates non-ST elevation acute coronary syndromes. The incidence of shock in the PURSUIT trial was 2.9% (1995–97),6 similar to the 2.5% incidence reported in the non-ST elevation arm of the GUSTO II-B trial (1994–95).7 A number of strategies that centre on reducing the time to effective treatment may help decrease the incidence of shock. These include public education to decrease the time to hospital presentation, triage and early transfer of high risk patients to selected centres, and early primary percutaneous coronary intervention (PCI) or rescue PCI for failed thrombolysis in high risk patients.

PREDICTING AND PREVENTING SHOCK

The onset of cardiogenic shock in a patient following ST elevation MI heralds a dismal …

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