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A 64-year-old man presents 6 hours after the onset of severe central crushing chest pain. He is pale, diaphoretic, confused and breathless. Blood pressure is 84/50 mmHg, heart rate 118/min, respiratory rate 28/min, SpO2 88 percent on room air. JVP is raised to the angle of the jaw. He has bilateral crackles to mid-zones, a gallop rhythm and cold, mottled peripheries. Urine output is 15 mL since catheterisation 1 hour ago. The 12-lead ECG shows ST elevation in V1 to V4 with reciprocal changes. Lactate is 4.8 mmol/L.[7]
Questions
a) What is the clinical diagnosis, and what three criteria (from the SHOCK-trial definition) support it? (2 marks)
Cardiogenic shock complicating an acute anterior STEMI. The diagnostic criteria are: (1) systolic blood pressure below 90 mmHg for at least 30 minutes (here 84 mmHg), (2) signs of end-organ hypoperfusion (confusion, cold mottled peripheries, oliguria under 30 mL/hour, raised lactate at 4.8 mmol/L), and (3) haemodynamic confirmation of a cardiac cause (CI at or below 2.2 with PCWP over 15 mmHg in SHOCK; congestion here implies a raised filling pressure).[1][9]
b) Outline your immediate resuscitation and pharmacological haemodynamic support with named first-line agents and the trial evidence that no inotrope has proven mortality benefit. (3 marks)
ABCDE, sit upright, high-flow oxygen titrated to saturations, non-invasive ventilation (CPAP) for pulmonary oedema; two large-bore cannulae, arterial line, central venous access, urinary catheter. Pharmacological support: inotrope — dobutamine or milrinone (CAPITAL DOREMI: no difference on the primary composite) plus first-line vasopressor noradrenaline (SOAP-II: more arrhythmia and, in the CS subgroup, more 28-day deaths with dopamine). Avoid fluids (the wedge is high). Activate the STEMI pathway and emergency PCI team — the single biggest mortality reducer is early revascularisation.[5][6][1]
c) What is the definitive management, and cite the relevant landmark trial evidence? (3 marks)
Emergency revascularisation of the infarct-related artery — the only AMI-CS treatment supported by randomised trials. In cardiogenic shock with multivessel disease, the CULPRIT-SHOCK trial (Thiele, NEJM 2017) showed culprit-lesion-only PCI reduced the composite of death OR severe renal failure needing RRT (relative risk 0.83, P equal to 0.01) compared with immediate multivessel PCI — staged complete revascularisation is done later. The SHOCK trial (Hochman, NEJM 1999) established that early revascularisation reduced 6-month and 1-year mortality (benefit confined to under 75). Escalate to mechanical circulatory support (Impella or VA-ECMO) if shock is refractory or deteriorating (SCAI D/E). Routine IABP is not recommended (IABP-SHOCK II — no mortality benefit).[4][1][2][3][7]
d) List two complications and one common pitfall. (2 marks)
Complications: (1) refractory ventricular arrhythmia (VT/VF) and cardiac arrest; (2) acute kidney injury / type 1 cardiorenal syndrome needing RRT. Common pitfall: treating cardiogenic shock as if it were septic or hypovolaemic — flooding a high-wedge patient with fluid causes flash pulmonary oedema and worsens RV strain; always check JVP/echo/wedge before fluids.[7]
References9ShowHide
- [1]Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators N Engl J Med, 1999.PMID 10460813
- [2]Hochman JS, Sleeper LA, White HD, et al. One-year survival following early revascularization for cardiogenic shock JAMA, 2001.PMID 11176812
- [3]Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock N Engl J Med, 2012.PMID 22920912
- [4]Thiele H, Akin I, Sandri M, et al. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock N Engl J Med, 2017.PMID 29083953
- [5]De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock N Engl J Med, 2010.PMID 20200382
- [6]Mathew R, Di Santo P, Jung RG, et al. Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock N Engl J Med, 2021.PMID 34347952
- [7]Samsky MD, Morrow DA, Proudfoot AG, et al. Cardiogenic Shock After Acute Myocardial Infarction: A Review JAMA, 2021.PMID 34751704
- [8]Jentzer JC, van Diepen S, Barsness GW, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit J Am Coll Cardiol, 2019.PMID 31548097
- [9]Forrester JS, Diamond GA, Swan HJ Correlative classification of clinical and hemodynamic function after acute myocardial infarction Am J Cardiol, 1977.PMID 835473