Infarct-related cardiogenic shock: revascularisation timing, culprit-only PCI and device selection

This page is about one patient: the person whose infarct has put them into shock. ESC 2023 names ischaemia-related heart failure, acute severe mitral regurgitation and mechanical complications as the major precipitating causes of shock in ACS.^[2] The decisions that follow are when to open the artery, where to do it, how many arteries to treat and whether a device helps.^[2][1] Shock staging, drugs and device physiology in general sit on the main cardiogenic shock page.

• Related topic: Cardiogenic shock: staging, MCS selection and outcomes.
• Related topic: Early mechanical complications of acute myocardial infarction.
• Related topic: STEMI: reperfusion strategy, timing and transfer decisions.

Definition and how often it happens

ESC 2026 defines cardiogenic shock as a state of critical end-organ hypoperfusion caused by primary cardiac dysfunction.^[1] Its biochemical marker is best measured by arterial lactate, and a value above 2 mmol/L is required.^[1] The same guideline sets no blood pressure cut-off, and says any arbitrary threshold has inherent limitations.^[1]

^{[2] [3]}

ESC 2023 says shock occurs more often in the presence of complete coronary occlusion.^[2] The SHOCK trial registry shows what lies behind the label.^[9] It registered 1190 patients with shock complicating acute MI between April 1993 and August 1997.^[9]

Causes of shock complicating acute MI in the SHOCK Trial Registry (abstract, selected categories)

^[9]

In-hospital mortality in that registry was 60%, and ventricular septal rupture carried a significantly higher mortality (87.3%) than every other category.^[9] The registry authors report a mechanical complication as the cause of shock in 12%.^[9]

^[9]

How an infarct produces shock

In the SHOCK registry, most shock complicating acute MI was predominant left ventricular failure.^[9] The two other routes matter because they change the treatment: a mechanical lesion (papillary muscle rupture, septal rupture or free-wall rupture), or a failing right ventricle.^[3][1]

ESC 2026 describes how a failing right ventricle spreads the problem.^[1] Raised right ventricular and right atrial pressures cause systemic congestion and, in more advanced stages, hypoperfusion.^[1] The failing right ventricle can also impair LV filling and reduce systemic cardiac output through ventricular interdependence.^[1]

The devices act on different parts of this circuit (ACC/AHA 2025 text).^[3] IABP counterpulsation improves coronary perfusion and reduces cardiac afterload.^[3] Microaxial flow pumps unload the LV by draining blood from it into the ascending aorta, and depend on adequate right ventricular function to fill the LV.^[3] VA-ECMO provides both blood flow and oxygenation but increases afterload.^[3] ESC 2026 adds that ECLS may harm the heart itself through that afterload increase, which active unloading aims to mitigate.^[1]

Recognition and first tests

Shock can present with a normal blood pressure: ESC 2026 says it may also present as hypoperfusion with normotension.^[1] ESC 2026 defines no specific blood pressure cut-off, and measures the biochemical sign of inadequate tissue perfusion with arterial lactate, requiring a value above 2 mmol/L.^[1] ACC/AHA 2025 says 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]

First tests in suspected infarct-related shock (selected rows)

^{[2] [3] [4]}

ESC 2023 says ST-segment elevation in V3R and V4R is highly suggestive of ongoing right ventricular ischaemia.^[2]

Causes to separate at the bedside

• Mechanical complication. ESC 2023 lists acute severe mitral regurgitation and mechanical complications among the major precipitants; in the SHOCK registry, ventricular septal rupture carried an in-hospital mortality of 87.3%. Details are on the mechanical complications page.^[2][9]
• Right ventricular infarction. ESC 2026 names acute MI involving the right ventricle, with pulmonary embolism, as causes of decompensated right heart failure to exclude during initial evaluation and treat.^[1]
• Tamponade. It accounted for 1.4% of shock in the SHOCK registry.^[9]
• Mechanical complications before lysis. ESC 2023 says fibrinolysis should be considered in STEMI with shock if primary PCI is not available within 120 min of STEMI diagnosis and mechanical complications have been ruled out (Class IIa, Level C).^[2]

Open the artery: rows and timing

All three bodies tell you to revascularise the infarct-related artery.^[2][3][4] ESC 2023 Table 3 defines an immediate invasive strategy as emergency coronary angiography, meaning as soon as possible, with PCI or CABG of the IRA if indicated.^[2] ESC 2023 also says invasive management strategies are time sensitive, and patients triaged to an immediate invasive strategy should receive emergency angiography as soon as possible.^[2]

Revascularisation and timing rows for infarct-related shock (selected)

^{[2] [3] [4]}

• How fast (ACC/AHA 2025 supportive text; no class or level given): primary PCI should be performed in STEMI with cardiogenic shock as soon as possible, ideally within 90 minutes, to reduce the mortality rate.^[3]
• Delay costs lives (ACC/AHA 2025 synopsis): in STEMI with haemodynamic instability, treatment delays to primary PCI are associated with worse survival.^[3]
• NSTEMI (ACC/AHA 2025 synopsis): immediate revascularisation with PCI or CABG is also recommended in high-risk NSTEMI with cardiogenic shock; the NSTE-ACS supportive text puts an immediate invasive strategy at less than 2 hours from hospital admission.^[3]
• Late presenters at a non-PCI hospital (ACC/AHA 2025 synopsis): STEMI presenting 12 hours or more after symptom onset should be transferred to a PCI-capable facility when possible; with haemodynamic instability or a large territory at risk, where timely primary PCI is not possible, the benefits of fibrinolysis likely outweigh those of prolonged transfer.^[3]
• Australia and New Zealand (MJA 2026 summary, consensus row for STEMI/ACOMI in general): deliver primary PCI within 60 min of arrival at a PCI-capable centre, or within 90 min of first hospital arrival after transfer from a non-PCI centre.^[4]

^{[2] [3] [4]}

The SHOCK trial: a benefit that arrived late

^{[6] [7] [8]}

• 1 year (JAMA 2001 report of the same trial): survival 46.7% with early revascularisation versus 33.6% with initial medical stabilisation (absolute difference 13.2%); of 10 prespecified subgroups, only age interacted, with benefit apparent only below 75 years.^[7]
• 6 years (JAMA 2006 report): the 13-percentage-point survival difference at 1 year remained stable at 3 and 6 years; 6-year survival was 32.8% versus 19.6%.^[8]
• How the guidelines report it: ESC 2023 says 64% of the revascularisation arm had PCI and 36% CABG, with no mortality difference at 30 days but lower mortality at 6 months; ACC/AHA 2025 says the benefit was maintained through 1 and 6 years.^[2][3]

Getting the patient to a shock centre

Revascularisation needs a catheter laboratory, and device support needs a team.^[2][1] ESC 2023 says patients with shock complicating ACS should go as soon as possible to a tertiary care centre, such as a shock centre, where invasive angiography can be performed.^[2] That holds with or without ST-segment elevation or equivalent ECG patterns, and the centre is one supported by specialists with relevant experience (the Shock Team).^[2]

• Escort (ESC 2023 text): personnel equipped and trained to manage life-threatening arrhythmias and cardiac arrest should accompany patients transferred between facilities during the time window in which they require continuous rhythm monitoring.^[2]
• Unstable NSTE-ACS (ACC/AHA 2025 supportive text): patients with ACS and unstable features at a non-PCI-capable hospital should be immediately transferred to a PCI-capable facility with a goal of immediate angiography.^[3]
• Shock teams (ACC/AHA 2025 text, mechanical complications section): emerging data after the creation of shock teams support transfer of haemodynamically unstable patients from community hospitals to centres with multidisciplinary expertise.^[3]
• What transfer looked like in SHOCK: in an analysis of 969 STEMI patients with LV failure from the SHOCK trial and registry, the 46% who were transferred were revascularised later (median 7.3 vs 3.9 hours) but had similar adjusted in-hospital mortality to direct admissions (55% vs 56%).^[12]
• Benefit after transfer (same analysis): in-hospital mortality was lower with early revascularisation than with no or late revascularisation, both in transferred patients (41% vs 53%) and in direct admissions (55% vs 71%). The authors call transfer patients a selected population.^[12]
• The trialists in 2001: the SHOCK 1-year report recommends rapid transfer of patients with AMI complicated by shock, particularly those younger than 75 years, to centres able to provide early angiography and revascularisation.^[7]

Culprit only: what to do with the other arteries

Nearly 80% of ACS patients with shock have multivessel disease, so the question arises on the table in most of them.^[2] ESC 2023 says PCI during the index procedure should be restricted to the IRA, on the basis of CULPRIT-SHOCK, which included ACS with and without ST-segment elevation or equivalent.^[2]

Culprit-only rows in shock (all shock rows on non-culprit PCI in the guidelines checked)

^{[2] [3] [5] [4]}

The rule for stable patients is the opposite.^[2][4] In haemodynamically stable STEMI undergoing primary PCI, ESC 2023 recommends complete revascularisation during the index PCI or within 45 days (Class I, Level A).^[2] NHFA/CSANZ 2025 (MJA 2026 summary) says to perform PCI of suitable non-IRAs in haemodynamically stable people with STEMI/ACOMI and multivessel disease (strong; high certainty).^[4]

^{[13] [14]}

• The price of leaving arteries alone (1-year report): repeat revascularisation (32.3% vs 9.4%) and rehospitalisation for heart failure (5.2% vs 1.2%) were more frequent with culprit-lesion-only PCI.^[14]
• How the guidelines read it: ESC 2023 reports the 30-day reduction in death or renal replacement therapy (RR 0.83) and no significant mortality difference at 1 year; ACC/AHA 2025 reports that death or renal replacement therapy was significantly higher with multivessel PCI at 30 days and 1 year.^[2][3]
• The caveat (ACC/AHA 2025): CULPRIT-SHOCK enrolled patients only if there was an identifiable culprit lesion; with an unstable-appearing non-culprit lesion or an uncertain culprit, the decision on multivessel PCI may be more nuanced.^[3]

Newer reports on the culprit question

Two later analyses of CULPRIT-SHOCK support its result, and a DanGer Shock substudy points the other way.^[15][16][18] Two are analyses of CULPRIT-SHOCK itself; the third is a non-randomised comparison inside a device trial.^[15][16][18]

• Bayesian reanalysis of CULPRIT-SHOCK (2024): with a non-informative prior, the median relative risk was 0.82 (95% highest posterior density 0.66 to 1.04), a 95% probability of benefit and a 59% probability of reaching the authors' minimal clinically important difference (relative risk below 0.84).^[15]
• Same reanalysis, secondary outcomes: possible benefit in mortality (RR 0.85) and renal replacement therapy (RR 0.72), but higher risks of recurrent MI (RR 2.84) and urgent revascularisation (RR 2.88).^[15]
• Cardiac arrest (CULPRIT-SHOCK trial and registry, 2023): 550 of 1015 patients (54.2%) had cardiac arrest; in the randomised trial, culprit lesion-only PCI was superior to immediate multivessel PCI with and without arrest (P for interaction 0.6).^[16]
• DanGer Shock multivessel substudy (2025): an exploratory as-treated analysis of STEMI-related shock with multivessel disease, excluding comatose resuscitated patients, found all-cause mortality of 61% with culprit-only PCI and 50% with immediate multivessel PCI over a median follow-up of 45 days; the adjusted OR of 0.40 (95% CI 0.19 to 0.83) means 60% lower odds of death with immediate multivessel PCI.^[18]
• Reading the substudy: its authors call it exploratory, and it compares the PCI strategy actually used (as treated), not a randomised allocation; the guideline culprit-only rows rest on CULPRIT-SHOCK.^[18][2]

^{[13] [14] [15] [16] [18]}

When the answer is surgery

Most patients go to PCI at the diagnostic angiogram, if revascularisation is indicated.^[2] ESC 2023 calls surgical revascularisation a valuable option when attempted PCI of the IRA has failed or the anatomy is not amenable to PCI.^[2] ACC/AHA 2025 says observational studies suggest emergency CABG remains an option in shock not amenable to primary PCI or when PCI is unsuccessful.^[3] For emergency CABG, ESC 2023 says peri-operative strategies, particularly prophylactic or on-demand mechanical circulatory support, may be considered on the basis of pre-operative clinical status.^[2]

• ESC 2023 examples of pre-operative status: age, comorbidities, electrical instability, the extent of jeopardised myocardium, the duration of ischaemia from symptom onset, right ventricular involvement, and technical or logistical feasibility of cardiac surgery.^[2]

Mechanical circulatory support: selecting the patient

The device question in infarct-related shock is now about selection.^[1][27] Five randomised trials frame it: DanGer Shock, ECLS-SHOCK, IABP-SHOCK II and the early-stopped EURO SHOCK in infarct-related shock, and ECMO-CS in rapidly deteriorating or severe cardiogenic shock; two individual patient data meta-analyses pool randomised trials in infarct-related shock.^{[17][20][24][21][23][26][27]} The rows below give each body's position separately.^[1][3][4]

Temporary MCS rows in infarct-related shock, by body (selected)

^{[1] [3] [4]}

• Who is "selected" (ACC/AHA 2025 supportive text): patients with features consistent with the DanGer Shock inclusion criteria; in particular STEMI with SCAI shock stage C, D or E, not comatose, with adequate peripheral vasculature for large-bore access.^[3]
• Why only 2a (ACC/AHA 2025): the class balances the reduction in death against the serious complications seen in DanGer Shock, including bleeding, limb ischaemia and renal replacement therapy.^[3]
• Australian text (MJA 2026): the guideline supports left ventricular assist devices in select people with STEMI/ACOMI and shock, given potential survival benefits despite increased bleeding and vascular complication risks; the reference behind that sentence is the DanGer Shock report.^[4]
• Routine IABP and VA-ECMO (MJA 2026 text): not recommended because of an increased risk of bleeding and vascular complications with no survival benefit, though they may be considered in select cases.^[4]

DanGer Shock: the trial behind the pump rows

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DanGer Shock: entry criteria and effect as reported

^{[3] [17]}

• Symptom delay (DanGer Shock secondary analysis, 2026): in 345 of the 355 patients, 180-day mortality rose across quartiles of time from symptom onset to randomisation (36%, 53%, 59% and 62%), but patients with longer delays were also older and more often women.^[19]
• Pump effect by delay (same analysis): odds ratio 0.51 (95% CI 0.31 to 0.84) in the three earliest quartiles combined and 0.92 (0.38 to 2.22) in the latest, with P for interaction 0.26; the authors say the benefit appeared to weaken with longer delay.^[19]

The neutral and negative device trials

• ECLS-SHOCK (randomised, multicentre, 2023): acute MI with shock and planned early revascularisation; early ECLS plus usual treatment versus usual treatment alone. Death at 30 days was 47.8% versus 49.0% (relative risk 0.98; P = 0.81) among 417 analysed.^[20]
• ECLS-SHOCK harms: moderate or severe bleeding 23.4% versus 9.6%, and peripheral vascular complications warranting intervention 11.0% versus 3.8%.^[20]
• IABP-SHOCK II (randomised, open-label, multicentre, 2012): 600 patients with shock complicating acute MI, all expected to undergo early revascularisation; death at 30 days was 39.7% with IABP and 41.3% without (relative risk 0.96; P=0.69).^[24]
• IABP-SHOCK II at 6.2 years (later report): mortality 66.3% versus 67.0% (relative risk 0.99); the authors note two thirds of patients with shock died despite revascularisation.^[25]
• ECMO-CS (randomised, multicentre, 2023): rapidly deteriorating or severe cardiogenic shock (ESC 2023 reports 51% with STEMI); immediate VA-ECMO versus an early conservative strategy that allowed downstream VA-ECMO. The 30-day composite of death, resuscitated arrest or another MCS device was 63.8% versus 71.2% (P=0.21), and 39% of the conservative arm received VA-ECMO.^[21][2]
• ECMO-CS at 1 year (later report): death 69.0% versus 67.8% (hazard ratio 1.02); the authors add that immediate ECMO might be beneficial in advanced haemodynamic compromise.^[22]
• EURO SHOCK (multicentre, randomised, 2023): persistent shock 30 minutes after primary PCI of the culprit; stopped after 35 patients because of the COVID-19 pandemic, with 30-day mortality 43.8% with VA-ECMO and 61.1% with standard therapy (P=0.22); the authors say no definite conclusions can be drawn.^[23]

Pooled data

• VA-ECMO individual patient data meta-analysis (Lancet 2023): four randomised trials (567 patients) of early routine VA-ECMO versus optimal medical therapy alone in infarct-related shock; no significant reduction in 30-day death (OR 0.93; 95% CI 0.66 to 1.29), with more major bleeding (OR 2.44) and peripheral ischaemic vascular complications (OR 3.53).^[26]
• Temporary MCS individual patient data meta-analysis (Lancet 2024): randomised trials of early routine active MCS versus control with 6-month mortality, nine reports and 1114 patients; no significant benefit of early unselected MCS on 6-month mortality (HR 0.87; 95% CI 0.74 to 1.03).^[27]
• Same meta-analysis, the subgroup: patients with ST-elevation shock without risk of hypoxic brain injury had lower mortality with MCS (HR 0.77; 95% CI 0.61 to 0.97).^[27]
• Same meta-analysis, harms across all patients: major bleeding (OR 2.64) and vascular complications (OR 4.43) were more frequent with MCS than with control.^[27]
• What ESC 2026 takes from it: a recent meta-analysis suggests temporary MCS is beneficial in highly selected ST-elevation MI with shock and no hypoxic brain injury, although rates of severe complications remain high.^[1]

Put together, the pump rows apply to a defined STEMI patient, and the active-device trials show more bleeding and vascular complications.^{[1][3][17][20][27]} ESC 2026 says routine use of microaxial flow pumps in cardiogenic shock is not recommended.^[1] It says the decision to use an IABP should be highly individualised, based on patient factors and the availability of alternatives.^[1] ACC/AHA 2025 adds that best practices for insertion, including fluoroscopy and ultrasound, should be used when feasible for femoral access.^[3]

^{[1] [3] [4] [3] [1]}

When a mechanical complication is the cause

The SHOCK registry found a mechanical complication behind 12% of infarct-related shock.^[9] ACC/AHA 2025 lists ventricular septal rupture, mitral insufficiency from papillary muscle infarction or rupture, and free-wall rupture, and says timely reperfusion has reduced their incidence.^[3] Here the culprit artery is not the whole problem.^[2] ESC 2023 says surgical or percutaneous treatment may be indicated, with the strategy decided by Heart Team discussion.^[2]

Mechanical complication rows when shock is the presentation (selected)

^{[2] [1] [3]}

• Why caution in a large ventricular septal defect (ESC 2026 footnote e): because of the potential increase of left-to-right interventricular shunt with VA-ECLS, or shunt inversion with a microaxial flow pump.^[1]
• Where (ACC/AHA 2025 text): transfer to a Level 1 cardiac intensive care unit with temporary MCS devices and experienced surgical, interventional, heart failure and palliative care teams is recommended.^[3]
• Surgical risk (ACC/AHA 2025): surgical mortality is highest in patients with cardiogenic shock and in those needing early emergency or urgent intervention after AMI.^[3]
• The ESC 2023 routine-IABP row excludes mechanical complications: it says the routine use of an IABP is not recommended in ACS with shock and without mechanical complications (Class III, Level B).^[2]

Diagnosis, repair timing and the individual lesions are covered on the mechanical complications page: Early mechanical complications of acute myocardial infarction.^[3]

Right ventricular infarction and shock

Isolated right ventricular shock made up 2.8% of the SHOCK Trial Registry.^[9] In the SHOCK trial registry, 49 of 933 patients had shock from predominant right ventricular failure and 884 from LV failure.^[10] The RV patients were younger, with less previous MI, less anterior MI and less multivessel disease (34.8% vs 77.8%).^[10] Shock was diagnosed sooner after the infarct (median 2.9 vs 6.2 h).^[10]

• Outcome (SHOCK registry): in-hospital mortality was 53.1% with predominant RV shock and 60.8% with LV shock (p = 0.296), and the influence of revascularisation on mortality did not differ; the authors call RV-shock mortality unexpectedly high and similar to LV shock.^[10]
• RV dysfunction is common across infarct-related shock: in a retrospective analysis of patients with available haemodynamics in the SHOCK trial (139) and registry (258), 38% and 37% had RV dysfunction, which was not associated with 30-day or 6-month survival; the authors say routine assessment with pulmonary artery catheterisation allows its detection.^[11]
• Find it on the ECG: ESC 2023 recommends V3R, V4R and V7–V9 in inferior STEMI or suspected total occlusion with inconclusive standard leads (Class I, Level B), and calls ST elevation in V3R and V4R highly suggestive of ongoing RV ischaemia.^[2]
• Nitrates: ESC 2023 says not to give them in RV infarction (among other listed conditions); ACC/AHA 2025 says to avoid intravenous nitroglycerin in suspected RV infarction.^[2][3]
• Ventilation (ESC 2026): non-invasive positive pressure ventilation decreases venous return and should be used with caution in reduced preload reserve and hypotension, that is, decompensated right-sided heart failure.^[1]
• Devices: microaxial flow pumps depend on adequate right ventricular function to fill the LV (ACC/AHA 2025); DanGer Shock excluded overt RV failure (ACC/AHA 2025); ESC 2026 says multiple device combinations are feasible, addressing specific needs for LV unloading or combined left and right ventricular support.^[3][1]

^{[10] [2] [3] [1]}

Shock team, shock centre and the cardiac intensive care unit

Shock care is a team decision made in a unit that can deliver it.^[1][3] ESC 2026 recommends a multidisciplinary Shock Team in potential candidates for temporary MCS, to guide device selection (modality and type) based on patient and heart failure characteristics (Class I, Level C).^[1] Its text names a heart failure cardiologist, a cardiothoracic surgeon, an interventional cardiologist and an intensive care specialist, working at an experienced, high-volume advanced heart failure centre.^[1] ESC 2026 also recommends Shock Team consultation when shock is suspected and temporary MCS is a potential indication.^[1]

Team and unit rows (selected)

^{[1] [3] [2]}

• ESC 2023 text: after reperfusion, high-risk ACS patients, including all STEMI patients, should be admitted to a CCU or ICCU; the acute risk modifiers it lists include acute heart failure and/or hypoperfusion, cardiogenic shock and cardiac arrest with coma.^[2]
• What the unit needs (ESC 2023): staff should be thoroughly familiar with the management of all aspects of ACS, including arrhythmias, heart failure, mechanical circulatory support, invasive and non-invasive haemodynamic monitoring, respiratory monitoring, mechanical ventilation and temperature control.^[2]
• No dedicated CICU (ACC/AHA 2025): some hospitals may not have a dedicated CICU and care for MI patients within a general multipurpose ICU, which requires trained providers with sufficient expertise in cardiac patients.^[3]
• Mechanical complications (ACC/AHA 2025 text): transfer to a Level 1 CICU with temporary MCS devices and multidisciplinary teams is recommended.^[3]

Complications and pitfalls

• Treating every artery at the first sitting: in ACS presenting in shock with multivessel disease, ESC 2023 recommends IRA-only PCI during the index procedure (Class I, Level B); 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]
• Applying the stable-patient rule: ESC 2023 recommends complete revascularisation during the index PCI or within 45 days for haemodynamically stable STEMI (Class I, Level A), not for shock.^[2]
• A pump for everyone: ESC 2026 says temporary MCS is not recommended in unselected patients with shock caused by acute MI, due to risk of harm (Class III, Level B1).^[1]
• A pump in the wrong patient: DanGer Shock excluded comatose patients after out-of-hospital arrest and overt RV failure (ACC/AHA 2025).^[3]
• Ignoring device harm: in DanGer Shock (randomised; STEMI with shock; pump plus standard care vs standard care alone) the composite safety end point was 24.0% versus 6.2% and renal-replacement therapy 41.9% versus 26.7%. In ECLS-SHOCK (randomised; acute MI with shock; early ECLS vs usual treatment alone) moderate or severe bleeding was 23.4% versus 9.6%.^[17][20]
• Lysing a mechanical complication: ESC 2023 says fibrinolysis should be considered in STEMI with shock if primary PCI is not available within 120 min of STEMI diagnosis and mechanical complications have been ruled out (Class IIa, Level C).^[2]
• Nitrates in RV infarction: ESC 2023 says not to give them.^[2]
• Waiting for hypotension: ESC 2026 defines no specific blood pressure cut-off; it says biochemical hypoperfusion is best measured by arterial lactate, where a value above 2 mmol/L is required.^[1]

Prognosis

Mortality remains high despite revascularisation.^[3][25] ACC/AHA 2025 gives an early mortality of 40% to 50% for shock after STEMI.^[3] In IABP-SHOCK II, a randomised trial of IABP versus no IABP in shock complicating acute MI, mortality at 6.2 years was 66.3% versus 67.0%; the authors note that two thirds of patients died despite revascularisation.^[24][25]

• Hospital survivors (SHOCK, randomised trial, 6-year report): almost two thirds of hospital survivors treated with early revascularisation were alive 6 years later.^[8]
• Survival at 1 year (SHOCK, randomised trial): 46.7% with early revascularisation versus 33.6% with initial medical stabilisation.^[7]
• Cardiac arrest (CULPRIT-SHOCK trial and registry, 1015 patients): arrest was an independent predictor of 1-year mortality (HR 1.27; 95% CI 1.01 to 1.59).^[16]
• Time (DanGer Shock secondary analysis of 345 randomised patients): 180-day mortality rose with longer delay from symptoms to randomisation, from 36% in the earliest quartile to 62% in the latest.^[19]

Special populations

• After cardiac arrest, angiography (AHA 2025 post-cardiac arrest guideline): coronary angiography should be performed emergently after cardiac arrest with a suspected cardiac cause and persistent ST elevation, regardless of coma (COR 1, LOE B-NR). Emergency angiography is reasonable for selected patients with a suspected cardiac cause without ST elevation in the presence of cardiogenic shock, recurrent ventricular arrhythmias or significant ongoing ischaemia, regardless of coma (COR 2a, LOE B-NR).^[5]
• After cardiac arrest, multivessel disease (AHA 2025): in shock after cardiac arrest with multivessel coronary disease, immediate revascularisation of non-infarct-related lesions is not recommended over initial revascularisation of only the infarct-related artery (COR 3: No Benefit, LOE B-R).^[5]
• After cardiac arrest, devices (AHA 2025): in cardiogenic shock after cardiac arrest and ROSC, temporary MCS should not be routinely used (COR 3: No Benefit, LOE B-R); in highly selected patients with refractory shock after arrest and ROSC, it may be considered (COR 2b, LOE B-NR). Its text notes that the one RCT showing survival benefit with routine MCS included 20% cardiac arrest survivors but excluded OHCA patients comatose after ROSC.^[5]
• After cardiac arrest, other bodies: NHFA/CSANZ 2025 (MJA 2026 summary) says to perform emergency reperfusion after return of spontaneous circulation with persistent ST elevation on the ECG (strong; low certainty). For pump selection, the ESC 2026 row (a microaxial flow pump should be considered in selected patients with shock caused by ST-elevation MI with LV systolic dysfunction, to reduce the risk of death; Class IIa, Level B1) also sets the condition of no risk of hypoxic brain injury, which its footnote c defines as no out-of-hospital arrest with persistent Glasgow coma scale below 8 after return of spontaneous circulation, and no resuscitation or resuscitation lasting less than 10 min.^[4][1]
• Older patients: in the randomised SHOCK trial at 1 year, age was the only one of 10 prespecified subgroups to interact with treatment, and benefit was apparent only below 75 years (51.6% vs 33.3% survival).^[7]
• NSTE-ACS: ESC 2023 recommends an immediate invasive strategy with a working diagnosis of NSTE-ACS and at least one very high-risk criterion, the first listed being haemodynamic instability or cardiogenic shock (Class I, Level C). ACC/AHA 2025 says routine non-culprit PCI at the index procedure should not be performed in NSTE-ACS with shock (COR 3: Harm, LOE B-R).^[2][3]
• Women and later presenters: in the DanGer Shock delay analysis (secondary analysis of 345 randomised patients), patients with longer delays were older and more often women (15% rising to 34% across quartiles).^[19]

Evidence, guidelines and regional differences

The bodies agree on the artery and differ on the device.^[2][3][4][1] Among the guidelines checked, the newest ESC device rows are in its 2026 heart failure guideline, and the ACC/AHA rows are in its 2025 ACS guideline.^[1][3] NHFA/CSANZ uses GRADE strength and certainty, which are not ESC classes or ACC/AHA COR.^[4][2][3]

Where the bodies agree and differ (selected rows)

^{[2] [3] [1] [4]}

Rows that changed

• History (ESC 2021 heart failure guideline, shown only as dated history): the ESC 2026 revised-recommendations table records the 2021 row "IABP is not routinely recommended in post-MI cardiogenic shock" (III, B) as replaced by the 2026 row for unselected cardiogenic shock (III, B1).^[1]
• ESC 2023 short-term MCS row, partly replaced: ESC 2023 says short-term MCS may be considered in ACS with severe or refractory shock (Class IIb, Level C). Among the guidelines checked, the newer ESC 2026 rows apply instead for the microaxial flow pump in selected ST-elevation MI shock with LV systolic dysfunction and no risk of hypoxic brain injury (footnote c: no out-of-hospital arrest with persistent Glasgow coma scale below 8 after return of spontaneous circulation, and no resuscitation or resuscitation lasting less than 10 min) (IIa, B1), and for temporary MCS in unselected acute MI shock (III, B1).^[2][1]
• ESC 2023 text on devices: it said the role of VA-ECMO and micro-axial pumps in AMI was not well established and large-scale randomised trials were warranted, and that while MCS may be considered in selected patients with severe or refractory shock, caution should be exercised until further randomised data are available.^[2]
• Shock after cardiac arrest: for this population, the newer AHA 2025 post-cardiac arrest rows (see Special populations) sit beside the ACC/AHA 2025 ACS rows. They say temporary MCS should not be routinely used (COR 3: No Benefit, LOE B-R) and immediate non-infarct-related revascularisation is not recommended (COR 3: No Benefit, LOE B-R).^[5][3]

Australia and New Zealand

NHFA/CSANZ 2025 is read here through its 2026 MJA summary.^[4] Its shock subgroup has four rows: IRA-only PCI, no routine IABP, no routine VA-ECMO, and LV assist devices for select STEMI/ACOMI patients.^[4] ACOMI means ECG patterns of acute coronary occlusion MI beyond ST-segment elevation.^[4]

Guidelines checked

A row called newer, or current, is so among the guidelines checked for this topic:

• Sources of the rows and statements used: ESC acute coronary syndromes (2023; version-of-record PDF and HTML text); ESC heart failure (2026); ACC/AHA/ACEP/NAEMSP/SCAI acute coronary syndromes (2025; JACC text); AHA post-cardiac arrest care (2025, Part 11; for patients after cardiac arrest); NHFA/CSANZ acute coronary syndromes (2025), through its MJA 2026 summary.^{[2][1][3][5][4]}
• Not held as text, so not checked for this topic: the 2021 ACC/AHA/SCAI and 2018 ESC/EACTS revascularisation guidelines; the full NHFA/CSANZ guideline in Heart Lung Circ is not quoted.

Exam pearls

• SHOCK (randomised; 302 patients with shock due to LV failure complicating MI): 30-day mortality 46.7% with emergency revascularisation vs 56.0% with initial medical stabilisation (P=0.11); 6-month mortality 50.3% vs 63.1% (P=0.027).^[6][8]
• ACC/AHA 2025: emergency culprit revascularisation in ACS with shock is indicated irrespective of time from symptom onset (COR 1, LOE B-R).^[3]
• CULPRIT-SHOCK (randomised; 706 patients with multivessel disease, acute MI and shock): death or renal-replacement therapy at 30 days 45.9% with culprit-lesion-only PCI vs 55.4% with immediate multivessel PCI (relative risk 0.83).^[13]
• ESC 2026 "no risk of hypoxic brain injury": no out-of-hospital arrest with persistent GCS below 8 after ROSC, and no resuscitation or resuscitation under 10 min.^[1]
• DanGer Shock (randomised; STEMI with shock; microaxial flow pump plus standard care vs standard care alone): death from any cause at 180 days 45.8% vs 58.5% (HR 0.74); ACC/AHA 2025 gives a number needed to treat of 8.^[17][3]
• ECLS-SHOCK (randomised; acute MI with shock, early revascularisation planned): 30-day death 47.8% with early ECLS vs 49.0% with usual treatment alone. IABP-SHOCK II (randomised; 600 patients, early revascularisation expected): 30-day death 39.7% with IABP vs 41.3% without.^[20][24]
• SHOCK Trial Registry (1190 registered patients with shock complicating acute MI): ventricular septal rupture had a significantly higher in-hospital mortality (87.3%) than all other categories.^[9]
• ESC 2023: fibrinolysis should be considered in STEMI with shock (IIa C) if primary PCI is not available within 120 min of diagnosis and mechanical complications have been ruled out.^[2]

References27ShowHide

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3. [3]Rao SV, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2025.PMID 40013746
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