Invasive Management of AMI Complicated by Cardiogenic Shock

Authors:
Henry TD, Tomey MI, Tamis-Holland JE et al., on behalf of the American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Cardiovascular and Stroke Nursing.
Citation:
Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2021;Mar 4:[Epub ahead of print].

The following are key points to remember from the American Heart Association (AHA) Scientific Statement on invasive management of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS):

  1. CS remains the most common cause of mortality in patients with AMI.
  2. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating AMI (AMICS) 20 years ago.
  3. However, after an initial improvement in mortality related to revascularization, mortality rates have plateaued.
  4. A recent Society of Coronary Angiography and Interventions (SCAI) classification scheme was developed to address the wide range of CS presentations. After multivariable adjustment, there was a stepwise increase in risk of hospital mortality with increments of SCAI shock stages A–E. An important aspect of the SCAI classification is a cardiac arrest modifier.
  5. Classification, stabilization, and diagnostic evaluation of AMICS are prerequisites to tailored invasive therapy. Stable patients with risk factors for shock (stage A) or early shock (stage B) can generally proceed directly to coronary angiography and culprit lesion revascularization with continuous reassessment for signs and symptoms of progression of shock.
  6. Patients presenting in shock (stages C–E) may first require acute stabilization with attention to blood pressure, endorgan perfusion status, oxygenation, and acid-base status.
  7. Selected patients with late or extreme forms of shock (stage E) for whom invasive management is inconsistent with goals of care and unlikely to provide benefit should instead be evaluated for palliative care.
  8. A recent scientific statement from the AHA recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support (MCS) devices. However, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials.
  9. Until data become available from randomized clinical trials sufficiently powered to define risks and benefits of early MCS for patients with different stages of AMICS, an individualized approach to care and participation in clinical research protocols to test the utility of MCS in AMICS is recommended. Early MCS placement before percutaneous coronary intervention may be considered for patients with AMICS who exhibit refractory hemodynamic instability despite aggressive medical therapy.
  10. Finally, optimization of care of AMI complicated by CS requires a multidisciplinary team effort to coordinate early assessment and triage (including possible interhospital transfer), noninvasive and invasive diagnostics, coronary revascularization, and expert ongoing intensive care management, including a sophisticated understanding of the evolving pathophysiology and hemodynamics of AMICS.

Keywords: Acute Coronary Syndrome, Blood Pressure, Cardiac Surgical Procedures, Coronary Angiography, Coronary Occlusion, Critical Care, Heart Arrest, Heart Failure, Hemodynamics, Myocardial Infarction, Myocardial Revascularization, Palliative Care, Percutaneous Coronary Intervention, Perfusion, Risk Assessment, Risk Factors, Secondary Prevention, Shock, Cardiogenic


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