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STEMI complicated by cardiogenic shock

ESC Congress Report

  • Ryanodine receptor stabilizers are positive isotropes and may be helpful in cardiogenic shock.
  • Extracorporeal membrane oxygenator (ECMO) as a possible first-line therapy for cardiogenic shock.
  • Culprit PCI potentially superior to complete revascularization.
  • Nitrates and antibiotics may prevent multi-organ failure.

View the Slides from this session in ESC Congress 365

Although the incidence of cardiogenic shock has declined and outcome has markedly improved due to the routine use of primary PCI in the management of STEMI, it still remains associated with an unacceptably high mortality rate (50%).

Alexander Lyon (London, UK) provided an update on the use of inotropic support in cardiogenic shock. Although they are systematically used, there is limited evidence on their use during cardiogenic shock. There clearly is a clinical need for innovative drugs that stimulate the heart without further harming the surviving myocardium.  Ryanodine receptor stabilizers that reduce the calcium leak from the sarcoplasmatic reticulum are a new class of inotropic drugs that may be helpful in the management of cardiogenic shock.

Alain Combes (Paris, FR) proposed an earlier application of an extracorporeal membrane oxygenator (ECMO) as first-line therapy in the management of cardiogenic shock. ECMO is less expensive, more versatile and easier to set up than the expensive surgical ventricular assist devices (VAD).  The early institution of mechanical support with ECMO may prevent the development of multi-organ failure. This new strategy will tested in the Anchor trial.
Early institution of mechanical support can be facilitated by a mobile ECMO team that operates within a network of hospitals. The ECMO machine can be brought to patients in the peripheral community hospitals, allowing a more safe transport to the central, expert hospital.  This innovative approach is under evaluation in a hospital network in Paris.

The majority of the STEMI patients with cardiogenic shock have multivessel disease. Although the guidelines recommend performing complete revascularization, there is no evidence that this is associated with a better outcome than performing PCI only of the culprit vessel. Uwe Zeymer  (Ludwigshaven, DE) presented the results of recent registry and a post hoc analysis of the IABP shock trial that suggest that PCI of the culprit lesion, followed by a staged procedure could be the best strategy. This will be compared to a complete revascularisation strategy in the CULPRIT-Shock trial.

Development of multi-organ failure is a frequent lethal complication in patients with cardiogenic shock. Pascal Vranckx (Hasselt, BE) emphasized the importance of early recognition of this. Action should be taken early to restore both the macro- and the micro-circulation in order to prevent failure of the "big five" (lungs, intestine, kidney, liver and brain).

Paradoxically, administration of nitrates can be used to improve the microcirculation in cardiogenic shock and a single shot of a broad spectrum antiobiotic may prevent the development of sepsis due to translocation of intestinal bacteria.




STEMI complicated by cardiogenic shock

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.