EM · Cardiogenic shock
Cardiogenic shock in the emergency department
Also known as Cardiac shock · Post-MI shock · Pump failure shock
Cardiogenic shock — tissue hypoperfusion from primary pump failure; SCAI stages A to E (B-to-C boundary is hypoperfusion); cause-first management (early revascularisation — SHOCK; culprit-only PCI — CULPRIT-SHOCK); noradrenaline preferred over dopamine (SOAP II); dobutamine or milrinone as inotrope (DOREMI: neither superior); MCS (IABP-SHOCK II no 30-day benefit; DanGer Shock microaxial-flow-pump 180-day mortality benefit; ECLS-SHOCK no 30-day benefit from routine VA-ECMO). ACEM-primary, globally tagged.
Checked against its sources on 5 Sept 2026
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Red flags
- Cardiogenic shock complicating an MI is revascularised immediately — the infarct is the cause and the spiral will not stop while it is untreated
- Noradrenaline is the preferred vasopressor — dopamine carries a higher arrhythmia risk and is no longer first-line for shock
- A new pansystolic murmur with shock days after an infarct is a mechanical complication (VSD or papillary-muscle rupture) until proven otherwise — it needs surgery and mechanical support, not lytics
- The intra-aortic balloon pump has no mortality benefit (IABP-SHOCK II) — Impella unloads the left ventricle; VA-ECMO supports flow but raises LV afterload
- In multivessel MI with shock, treat the culprit lesion only (CULPRIT-SHOCK) — multivessel intervention during shock worsens the outcome
Meet the patient
A 62-year-old man is 4 hours into an anterior STEMI when the cath-lab is being prepared. He deteriorates in front of you: pale, clammy, mottled from the knees down, BP 74 over 52, HR 130, SpO2 90 per cent on 15 L oxygen, and he has passed 10 mL of urine in the last hour. The JVP is raised, there are bibasal crackles, and the bedside echo shows anterior akinesia with an ejection fraction of 18 per cent. The venous lactate is 6.2 mmol per litre. This vignette is assembled from the trial evidence: most SHOCK-trial infarcts were anterior, the median time from infarct to shock was 5.6 hours, and the mean age at enrolment was 66 plus or minus 10 years. [1]
This is the cold-and-wet phenotype — the Stevenson cold-and-wet — and the spiral is already turning. The two questions that decide his next 30 minutes are the two that decide every cardiogenic shock: what is the cause? (revascularise it) and what is the perfusion? (support it, then unload it). The trap is reaching for a pure alpha-agonist — the pressure number improves while the stroke volume falls and the patient dies.[9]
References21ShowHide
- [1]Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock (SHOCK). New England Journal of Medicine, 1999.PMID 10460813
- [2]Thiele H, Akin I, Sandri M, et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock (CULPRIT-SHOCK). New England Journal of Medicine, 2017.PMID 29083953
- [3]Thiele H, Akin I, Sandri M, et al. Intraaortic Balloon Pump in Cardiogenic Shock Complicating Acute Myocardial Infarction: Long-Term 6-Year Outcome of the Randomized IABP-SHOCK II Trial. Circulation, 2019.PMID 30586721
- [4]Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock (IABP-SHOCK II). New England Journal of Medicine, 2012.PMID 22920912
- [5]Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA, 2006.PMID 16757723
- [6]De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock (SOAP II). New England Journal of Medicine, 2010.PMID 20200382
- [7]Thiele H, Freund A, Gimenez MR, et al. Extracorporeal life support in infarct-related cardiogenic shock (ECLS-SHOCK). New England Journal of Medicine, 2023.PMID 37634145
- [8]van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation, 2017.PMID 28923988
- [9]Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Catheterization and Cardiovascular Interventions, 2019.PMID 31104355
- [10]Thiele H, Ohman EM, de Waha-Thiele S, et al. Management of cardiogenic shock complicating myocardial infarction: an update 2019. European Heart Journal, 2019.PMID 31274157
- [11]Kinch JW, Ryan TJ. Right ventricular infarction. New England Journal of Medicine, 1994.PMID 8139631
- [12]Josiassen J, Frydland M, Hassager C, et al. Randomized clinical trials of patients with acute myocardial infarction-related cardiogenic shock — a systematic review of used cardiogenic shock definitions and outcomes. Kardiologia Polska (Polish Heart Journal), 2021.PMID 34292563
- [13]Hochman JS, Sleeper LA, White HD, et al. One-year survival following early revascularization for cardiogenic shock. JAMA, 2001.PMID 11176812
- [14]Jentzer JC, van Diepen S, Barsness GW, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit. Journal of the American College of Cardiology, 2019.PMID 31548097
- [15]Møller JE, Engstrøm T, Jensen LO, et al. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. New England Journal of Medicine, 2024.PMID 38587239
- [16]Samsky MD, Morrow DA, Proudfoot AG, et al. Cardiogenic Shock After Acute Myocardial Infarction: A Review. JAMA, 2021.PMID 34751704
- [17]Kosaraju A, Pendela VS, Hai O. Cardiogenic Shock. StatPearls, 2026.PMID 29489148
- [18]Mathew R, Di Santo P, Jung RG, et al. Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock. New England Journal of Medicine, 2021.PMID 34347952
- [19]Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emergency Medicine Journal, 2023.PMID 36180168
- [20]Tehrani BN, Truesdell AG, Psotka MA, et al. A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock. JACC Heart Failure, 2020.PMID 33121700
- [21]Sliwa K, Petrie MC, van der Meer P, et al. Clinical presentation, management, and 6-month outcomes in women with peripartum cardiomyopathy: an ESC EORP registry. European Heart Journal, 2020.PMID 32840318