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Home | Articles | Cardiac | Cardiogenic Shock Complicating Acute Coronary Syndrome

Cardiogenic Shock Complicating Acute Coronary Syndrome

Last updated 27th March 2025

Last updated on 25th July 2013 by Calum Murray

Introduction

  1. Defined as systemic hypotension and hypoperfusion in the setting of adequate and usually elevated ventricular filling pressures
  2. Occurs in around 5% of acute MI
  3. Risk factors include older age, female gender, large MI, anterior MI, previous MI, diabetes and previous HT
  4. Mortality rate remains around 80-90%

Clinical Features

  1. Persistent hypotension – SBP below 80 or 90mm Hg, or mean BP 30mmHg lower than baseline level
  2. Pulmonary oedema
  3. Signs of hypoperfusion with cold peripheries, oliguria and confusion

Aetiology

  1. Severe LV dysfunction – the most common type
  2. Papillary muscle rupture
  3. Rupture of intraventricular septum
  4. Cardiac tamponade due to rupture of LV free wall
  5. RV infarction – typically inferior MI. Hypotension with raised JVP but no pulmonary congestion unless there is involvement of LV. ECG may show ST elevation in RV leads

Differential Diagnosis in Patients with Acute MI

  1. Haemorrhagic shock followed bleed due to thrombolysis 
  2. Septic shock due to indwelling catheters – likely to have warm rather than cold peripheries 
  3. Pulmonary emboli – increased JVP with acute right heart strain e.g. RAD or RBBB 
  4. Severe bradycardias e.g. complete heart block 
  5. Rapid atrial arrhythmias or VT 
  6. Hypovolaemia (eg previous diuretic)

Investigations

  1. Urgent echo to assess LV and RV function, and to detect mechanical complications of MI ie tamponade, severe MR or VSD
  2. Arterial blood gases

NB Pulmonary artery catheter used much less frequently than before

Management

  1. Discuss immediately with Duty Consultant 
  2. Options are to make comfortable if elderly with multiple co-morbidity or to transfer to Glasgow for angiography then PCI if young & previously fit
  3. Consider thrombolysis if appropriate with tenecteplase 
  4. Treat acute pulmonary oedema with IV diuretic and CPAP
  5. Consider intravascular volume loading In the absence of clinical evidence of volume overload (RV infarction).
  6. Consider inotropic therapy with Dobutamine 5µg/kg/min in the presence of clinical evidence of volume overload,
  7. Consider balloon pump/ ITU for ventilation if transferring to Glasgow

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