. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Management of cardiogenic shock complicating myocardial infarction: an update 2019 Holger Thiele 1,2 *, E. Magnus Ohman 3 , Suzanne de Waha-Thiele 4 , Uwe Zeymer 5 , and Steffen Desch 1,2 1 Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Stru ¨mpellstr. 39, 04289 Leipzig, Germany; 2 Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany; 3 Duke Heart Center, Duke University Medical Center, Box 3126 DUMC, Durham, NC 27710, USA; 4 Department of Internal Medicine/Cardiology/ Angiology/Intensive Care Medicine, University Heart Center Luebeck, Ratzeburger Allee 160, 23538 Lu ¨beck, Germany; and 5 Klinikum Ludwigshafen, Medizinische Klinik B, Bremserstraße 79, D-67063 Ludwigshafen, Germany Received 31 December 2018; revised 17 March 2019; editorial decision 8 May 2019; accepted 11 May 2019; online publish-ahead-of-print 4 July 2019 Cardiogenic shock (CS) remains the most common cause of death in patients admitted with acute myocardial infarction (AMI) and mortal- ity remained nearly unchanged in the range of 40–50% during the last two decades. Early revascularization, vasopressors and inotropes, fluids, mechanical circulatory support, and general intensive care measures are widely used for CS management. However, there is only limited evidence for any of the above treatment strategies except for revascularization and the relative ineffectiveness of intra-aortic bal- loon pumping. This updated review will outline the management of CS complicating AMI with major focus on state-of-the art treatment. ................................................................................................................................................................................................... Keywords Shock • Heart failure • Treatment • Percutaneous coronary intervention • Myocardial infarction • Assist device Introduction Ventricular failure subsequent to acute myocardial infarction (AMI) remains the most frequent cause of cardiogenic shock (CS) account- ing for more than 80% of cases. Mechanical complications of AMI rep- resent less frequent causes of CS [ventricular septal rupture (4%), free wall rupture (2%), and acute severe mitral regurgitation (7%)]. 1 Non-infarct-related CS may be caused by different diseases such as decompensated chronic heart failure, valvular heart disease, acute myocarditis, Takotsubo syndrome, or arrhythmias with heteroge- neous treatment targets. 2 The incidence of CS complicating AMI is still in the range of 3– 13%. 3–6 Recent registries showed contradictory data with a decreased, stable, or even increased incidence of CS. 3–6 Based on these data, approximately 40 000–50 000 CS patients per year are treated in the USA and approximately 60 000–70 000 in Europe. 7 Despite a more widespread implementation of early revasculariza- tion with subsequent mortality reduction to 40–50%, CS remains a leading cause of death in AMI. 3,4,6,8,9 Some recent registries even reported an increase in mortality rates which may be explained by an ageing population and increasing risk profiles of CS patients. 6,10,11 The underlying causes, pathophysiology, treatment of CS compli- cating AMI have been reviewed previously. 2,12 This 2019 update will focus on evidence-based therapeutic management of CS complicat- ing AMI with major emphasis on current guideline recommendations, revascularization strategies, intensive care unit (ICU) treatment, ad- junctive medication, and mechanical circulatory support (MCS) devi- ces. Furthermore, research areas and gaps in evidence will be elucidated. Definition of cardiogenic shock In general, CS is defined as a state of critical endorgan hypoperfusion and hypoxia due to primary cardiac disorders. 2 Pragmatically, the diagnosis of CS can be made on the basis of clinical criteria such as persistent hypotension without adequate response to volume re- placement and accompanied clinical features of endorgan hypoperfu- sion such as cold extremities, oliguria, or altered mental status. In addition, biochemical manifestations of inadequate tissue perfusion such as elevated arterial lactate are usually present. Although not mandatory in clinical practice, objective haemo- dynamic parameters such as reduced cardiac index and elevated pulmonary capillary wedge pressure are helpful for diagnosis * Corresponding author. Tel: þ49 341 865 1428, Fax: þ49 341 865 1461, Email: holger.thiele@medizin.uni-leipzig.de Published on behalf of the European Society of Cardiology. All rights reserved. V C The Author(s) 2019. For permissions, please email: journals.permissions@oup.com. European Heart Journal (2019) 40, 2671–2683 CLINICAL REVIEW doi:10.1093/eurheartj/ehz363 Clinical update Downloaded from https://academic.oup.com/eurheartj/article-abstract/40/32/2671/5528526 by guest on 06 September 2019