STEMI complicated by cardiogenic shock — case discussion

Presentation

Practice case (not a real patient). A 66-year-old man in an Australian metropolitan hospital with a PCI service presents 3 hours after the onset of chest pain with an anterior ST-elevation MI.^[1] His blood pressure is 84/56 mmHg and heart rate 116 bpm; he is confused, his extremities are cold and sweaty, he has passed little urine, and his arterial lactate is 4.8 mmol/L.^[1] He has had no cardiac arrest. Bedside echocardiography shows severe LV systolic dysfunction with normal right ventricular function and no mechanical complication.^[1]

Step 1 — Is this cardiogenic shock, and how severe?

Discussion:

• ESC 2026 defines cardiogenic shock as critical end-organ hypoperfusion caused by primary cardiac dysfunction; the biochemical manifestation of inadequate tissue perfusion is best measured by arterial lactate, with a value above 2 mmol/L required.^[1]
• His confusion, cold sweaty extremities and oliguria are in the ESC 2026 Table 12 hypoperfusion profile.^[1]
• He has hypoperfusion and needs intervention, which places him in SCAI stage C (classic), as printed in ESC 2026 Table 13.^[1]

Step 2 — First actions

• ESC 2026 recommends consulting the Shock Team in suspected cardiogenic shock with a potential indication for temporary MCS, and says the diagnostic work-up and rescue treatment should start promptly and simultaneously.^[1]
• ESC 2026: vasopressors, preferably norepinephrine, may be considered in cardiogenic shock to increase blood pressure and vital organ perfusion (Class IIb, Level C); its supplementary Table S16 lists norepinephrine at 0.2–1.0 μg/kg/min.^[1]
• Oxygen is recommended if SpO2 is below 90% or PaO2 below 60 mmHg, to correct hypoxaemia (ESC 2026, Class I, Level C).^[1]

Step 3 — The catheter laboratory

• ESC 2023: immediate coronary angiography and PCI of the infarct-related artery, if indicated, in shock complicating ACS (Class I, Level B); ACC/AHA 2025: in ACS with cardiogenic shock or haemodynamic instability, emergency revascularisation of the culprit vessel by PCI or with CABG is indicated to improve survival, irrespective of time from symptom onset (COR 1, LOE B-R).^[2][3]
• Result: an occluded proximal left anterior descending artery (the culprit) and severe stenoses in the right coronary and circumflex arteries.^[3]
• ESC 2023 recommends infarct-related-artery-only PCI during the index procedure for multivessel disease in ACS presenting in shock (Class I, Level B); staged PCI of the non-infarct arteries should be considered, based on ischaemia, symptoms, patient comorbidities and clinical condition (Class IIa, Level C).^[2]
• The NHFA/CSANZ 2025 row (MJA 2026 Table 3) agrees: in people with ACS and cardiogenic shock, perform PCI of the infarct-related artery only (strong; moderate certainty).^[5]

Step 4 — Still in shock: which device?

After culprit PCI and escalating norepinephrine, his shock remains severe and refractory; he is awake, and his femoral arteries are suitable for large-bore access.^[3]

• ESC 2026: temporary MCS with a microaxial flow pump should be considered in selected patients with shock caused by ST-elevation MI with LV systolic dysfunction and no risk of hypoxic brain injury, to reduce the risk of death (Class IIa, Level B1); he had no arrest and no resuscitation.^[1]
• ACC/AHA 2025: in selected patients with STEMI and severe or refractory shock, a microaxial intravascular flow pump is reasonable to reduce death (COR 2a, LOE B-R); its supportive text names non-comatose patients in SCAI stage C, D or E with adequate peripheral vasculature for large-bore access.^[3]
• Not a routine balloon pump or VA-ECMO: ESC 2026 does not recommend IABP in unselected cardiogenic shock (Class III, Level B1), and ACC/AHA 2025 does not recommend routine IABP or VA-ECMO in acute MI with shock (COR 3: No benefit, LOE B-R).^[1][3]
• Warn about harms: in DanGer Shock the composite safety end point (severe bleeding, limb ischaemia, haemolysis, device failure or worsening aortic regurgitation) occurred in 24.0% versus 6.2%, and renal-replacement therapy in 41.9% versus 26.7%.^[7]

Step 5 — Who decides, and what next?

• ESC 2026 recommends a multidisciplinary Shock Team in potential candidates for temporary MCS to guide device selection (Class I, Level C).^[1]
• ESC 2023 recommends admitting high-risk ACS patients, including all STEMI patients, to a CCU or intensive cardiac care unit after reperfusion, and lists cardiogenic shock among the acute risk modifiers.^[2]
• ESC 2026 says in-hospital management of decompensated HF can be divided into three general phases, and that patients with cardiogenic shock usually remain in phase 1 for several days and may never reach phase 2.^[1]

Learning points

• ESC 2026 defines cardiogenic shock as critical end-organ hypoperfusion caused by primary cardiac dysfunction, and says no specific blood pressure cut-off is defined.^[1]
• In multivessel disease with ACS presenting in shock, ESC 2023 recommends infarct-related-artery-only PCI during the index procedure (Class I, Level B), and staged PCI of the non-infarct arteries should be considered, based on ischaemia, symptoms, comorbidities and clinical condition (Class IIa, Level C).^[2]
• A multidisciplinary Shock Team is recommended in potential candidates for temporary MCS to guide device selection (ESC 2026, Class I, Level C); a microaxial flow pump should be considered in selected STEMI-related shock with LV systolic dysfunction and no risk of hypoxic brain injury, to reduce the risk of death (ESC 2026, Class IIa, Level B1).^[1]