Infarct-related cardiogenic shock — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 63-year-old man presents to a hospital with a catheter laboratory 3 hours after the onset of chest pain. He has an anterior STEMI and is in cardiogenic shock: systolic blood pressure 80 mmHg on norepinephrine, cold peripheries and an arterial lactate of 4.8 mmol/L. He has had no cardiac arrest and no resuscitation. Echocardiography shows severe LV systolic dysfunction (LVEF 25%), no mechanical complication and a non-failing right ventricle.^[1]

1. Give the ESC 2023 and ACC/AHA 2025 rows on revascularisation in this situation, with class and level or COR and LOE. (2)^[2][3]
2. Angiography shows an occluded proximal LAD culprit with 80% right coronary and 75% circumflex stenoses. What do ESC 2023 and ACC/AHA 2025 say about the other arteries? (2)^[2][3]
3. What did CULPRIT-SHOCK show at 30 days and at 1 year? (2)^[13][14]
4. Give the ESC 2026 row on a microaxial flow pump, and say why he meets its brain-injury condition. (2)^[1]
5. What did DanGer Shock show for death and for harm? (2)^[17]

Model answers — SAQ 1

1. ESC 2023: immediate coronary angiography and PCI of the IRA (if indicated) is recommended in cardiogenic shock complicating ACS (Class I, Level B) (1 mark).^[2] 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) (1 mark).^[3]
2. ESC 2023: in multivessel disease in ACS presenting in shock, IRA-only PCI during the index procedure is recommended (Class I, Level B), and staged PCI of the non-IRA should be considered (Class IIa, Level C), based on ischaemia, symptoms, comorbidities and clinical condition (1 mark).^[2] ACC/AHA 2025: in ACS complicated by cardiogenic shock, routine PCI of a non-infarct-related artery at the time of primary PCI should not be performed because of the higher risk of death or renal failure (COR 3: Harm, LOE B-R) (1 mark).^[3]
3. At 30 days, death or severe renal failure leading to renal-replacement therapy occurred in 45.9% with culprit-lesion-only PCI and 55.4% with immediate multivessel PCI (relative risk 0.83; 95% CI 0.71 to 0.96) (1 mark).^[13] At 1 year, death occurred in 50.0% versus 56.9% (relative risk 0.88; 95% CI 0.76 to 1.01), not significantly different, with more repeat revascularisation (32.3% versus 9.4%) after culprit-only PCI (1 mark).^[14]
4. 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) (1 mark).^[1] Footnote c defines no risk of hypoxic brain injury as no out-of-hospital arrest with persistent Glasgow coma scale below 8 after ROSC, and no resuscitation or resuscitation lasting less than 10 min; he has had no arrest and no resuscitation (1 mark).^[1]
5. Death from any cause at 180 days was 45.8% with the pump plus standard care versus 58.5% with standard care alone (hazard ratio 0.74; 95% CI 0.55 to 0.99) (1 mark).^[17] 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% (1 mark).^[17]

SAQ 2 (10 marks)

Practice scenario. A 68-year-old woman presents to a rural hospital without a catheter laboratory with an inferior STEMI and cardiogenic shock. Transfer for primary PCI would take more than 120 minutes from STEMI diagnosis. Bedside echocardiography shows no mechanical complication, and she has no contraindication to fibrinolysis.^[2]

1. Under ESC 2023, in which two conditions should fibrinolysis be considered, and what is the class and level? (2)^[2]
2. Which ECG leads does ESC 2023 recommend in inferior STEMI, with class and level, and what does ST elevation in V4R suggest? (2)^[2]
3. V4R shows ST elevation. Which drug class do ESC 2023 and ACC/AHA 2025 say to avoid? (2)^[2][3]
4. Where should she be treated, according to ESC 2023 text, and who should accompany the transfer? (2)^[2]
5. How did predominant RV shock compare with LV shock in the SHOCK registry? (2)^[10]

Model answers — SAQ 2

1. Fibrinolysis should be considered in STEMI patients presenting with shock if a primary PCI strategy is not available within 120 min from STEMI diagnosis (1 mark) and mechanical complications have been ruled out (1 mark); ESC 2023, Class IIa, Level C.^[2]
2. Additional leads (V3R, V4R and V7–V9) are recommended in inferior STEMI or if total vessel occlusion is suspected and standard leads are inconclusive (ESC 2023, Class I, Level B) (1 mark).^[2] ST elevation in V3R and V4R is highly suggestive of ongoing RV ischaemia (ESC 2023) (1 mark).^[2]
3. Nitrates: ESC 2023 says they should not be given in RV infarction (1 mark).^[2] ACC/AHA 2025 says to avoid intravenous nitroglycerin in suspected RV infarction (1 mark).^[3]
4. She 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 (ESC 2023 text) (1 mark).^[2] Personnel trained and equipped to manage life-threatening arrhythmias and cardiac arrest should accompany patients who need continuous rhythm monitoring during transfer (ESC 2023 text) (1 mark).^[2]
5. RV-shock patients were younger, with less previous MI, less anterior MI and less multivessel disease, and shock was diagnosed sooner after the MI (1 mark).^[10] In-hospital mortality was 53.1% versus 60.8% (p = 0.296), with a similar influence of revascularisation; the authors call RV-shock mortality unexpectedly high (1 mark).^[10]