Reperfusion therapy in cardiogenic shock complicating acute myocardial infarction

The most frequent cause of cardiogenic shock complicating acute myocardial infarction is extensive myocardial damage involving a relevant amount of my ocardium. Treatment is aimed at support for the circulation with the use of drugs and mechanical devices and at restoration of perfusion to the ischem ic myocardium as soon as possible. Therefore, emergency coronary angiograph y is indicated in all patients. Coronary angioplasty is the first option in patients with suitable anatomy because it is the fastest available techniq ue able to recanalize the infarct-related vessel. Stenting of the infarct a rtery must be considered because stent implantation has been shown to impro ve results in comparison with the balloon alone. Complete revascularization is likely to offer a better outcome in patients with multivessel disease. Coronary surgery is indicated as first-line intervention in patients who ha ve a coronary anatomy not suitable for angioplasty; it may also serve to co mplete revascularization in patients with multivessel disease initially tre ated with emergency coronary angioplasty. In a hospital without facilities for emergency coronary interventions, mechanical circulatory support with a n intra-aortic balloon pump should be instituted and thrombolysis started; then patients should be transferred immediately to a tertiary center to und ergo coronary angiography and revascularization procedures, if needed. In p atients not benefiting from this aggressive revascularization strategy who develop irreversible extensive myocardial damage, heart transplantation mus t be considered.