Anterior STEMI with cardiogenic shock at a regional hospital — case discussion

Presentation

Practice case (not a real patient). A 57-year-old man in a regional Australian town develops chest pain at home and calls an ambulance; he reaches the local hospital, which has no catheter laboratory, 90 minutes later. His ECG shows anterior STEMI. Systolic blood pressure is 82 mmHg despite fluid, his peripheries are cold, he is confused, and his arterial lactate is 4.2 mmol/L. He has had no cardiac arrest.^[1] A tertiary shock centre with a catheter laboratory, cardiac surgery and a Shock Team can deliver primary PCI within 90 minutes of his first hospital arrival, well within 120 minutes of STEMI diagnosis.

Step 1 — Name the problem

Discussion:

• This is cardiogenic shock complicating STEMI: ESC 2026 defines shock as critical end-organ hypoperfusion caused by primary cardiac dysfunction, with an arterial lactate above 2 mmol/L required and no fixed blood pressure cut-off.^[1]
• ESC 2023 says shock may occur in up to 4–11% of ACS and occurs more often with complete coronary occlusion; ACC/AHA 2025 gives about 10% of STEMI, with an early mortality of 40% to 50%.^[2][3]
• Emergency TTE is recommended in suspected ACS presenting with cardiogenic shock or suspected mechanical complications (ESC 2023, Class I, Level C); his shows severe LV systolic dysfunction (LVEF 25%), no septal rupture, no severe mitral regurgitation, no effusion and a normal-sized right ventricle.^[2]

Step 2 — Transfer, not lysis

• ESC 2023 text: patients with shock complicating ACS should be transferred as soon as possible to a tertiary care centre, such as a shock centre, where invasive angiography can be performed, supported by the Shock Team.^[2]
• The ESC 2023 fibrinolysis row (Class IIa, Level C) applies if primary PCI is not available within 120 min from STEMI diagnosis and mechanical complications have been ruled out; here primary PCI is available within that time, so he is transferred for primary PCI.^[2]
• ESC 2023 text: personnel trained and equipped to manage life-threatening arrhythmias and cardiac arrest should accompany patients who need continuous rhythm monitoring during transfer.^[2]
• NHFA/CSANZ 2025 (MJA 2026 summary, consensus row for STEMI/ACOMI): for people transferred from a non-PCI centre, deliver primary PCI within 90 min of first hospital arrival.^[4]

Step 3 — The catheter laboratory

Angiography shows an occluded proximal LAD, the clear culprit, with a 90% right coronary stenosis and a 70% circumflex stenosis: multivessel disease, which ESC 2023 says nearly 80% of ACS patients with shock have.^[2]

• ESC 2023: immediate coronary angiography and PCI of the IRA (if indicated) is recommended (Class I, Level B); ACC/AHA 2025: 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]
• ESC 2023: IRA-only PCI during the index procedure is recommended (Class I, Level B); ACC/AHA 2025: routine non-IRA PCI at primary PCI should not be performed (COR 3: Harm, LOE B-R); NHFA/CSANZ 2025: perform PCI of the IRA only (strong; moderate certainty).^[2][3][4]
• The LAD is stented; the right coronary and circumflex lesions are left for a staged decision, which ESC 2023 says should be considered based on ischaemia, symptoms, comorbidities and clinical condition (Class IIa, Level C).^[2]

Step 4 — Does he need a pump?

After PCI he remains hypotensive on norepinephrine, with a lactate of 4.0 mmol/L, and the Shock Team stages his shock as SCAI stage C. He is awake, has had no cardiac arrest and no resuscitation, has no overt right ventricular failure and has good femoral arteries for large-bore access.^[3][1]

• ESC 2026: 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). Footnote c defines no risk of hypoxic brain injury as no out-of-hospital cardiac arrest with persistent Glasgow coma scale below 8 after return of spontaneous circulation, and no resuscitation or resuscitation lasting less than 10 min; he meets each condition.^[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 SCAI stage C, D or E, not comatose, with adequate peripheral vasculature for large-bore access.^[3]
• ESC 2026 recommends a multidisciplinary Shock Team in potential candidates for temporary MCS, to guide device selection (Class I, Level C).^[1]
• The team weighs the DanGer Shock harms, a composite safety end point of 24.0% with the pump plus standard care vs 6.2% with standard care alone and renal-replacement therapy in 41.9% vs 26.7%, against death from any cause at 180 days of 45.8% vs 58.5% (hazard ratio 0.74).^[17]
• A routine IABP or VA-ECMO is not recommended in AMI with shock (ACC/AHA 2025, COR 3: No benefit, LOE B-R).^[3]

Step 5 — After the laboratory

• ACC/AHA 2025: patients with ACS and cardiogenic shock should be admitted to a CICU to reduce cardiovascular events (COR 1, LOE C-EO).^[3]
• ESC 2023 text: ICCU staff should be familiar with mechanical circulatory support, invasive and non-invasive haemodynamic monitoring, mechanical ventilation and temperature control.^[2]
• ACC/AHA 2025 text: mechanical complications commonly present within the first week after AMI with recurrent or refractory chest pain, or a new murmur with disproportionate heart failure, shock or sudden cardiac death.^[3]

Examiner pitfalls

• Stenting all three arteries at the first procedure: in shock with multivessel disease, ESC 2023 recommends IRA-only PCI during the index procedure (Class I, Level B), and ACC/AHA 2025 says routine non-IRA PCI at the time of primary PCI should not be performed (COR 3: Harm, LOE B-R).^[2][3]
• Giving fibrinolysis when primary PCI is available within 120 min of STEMI diagnosis: the ESC 2023 row (Class IIa, Level C) says fibrinolysis should be considered in STEMI with shock if primary PCI is not available within 120 min and mechanical complications have been ruled out.^[2]
• Placing a pump in every patient in shock: temporary MCS in unselected patients with shock caused by acute MI is not recommended (ESC 2026, Class III, Level B1).^[1]