PCI First in STEMI Patients with Cardiogenic Shock
Primary Strategy: Immediate Culprit Vessel Revascularization
- The American College of Cardiology recommends emergency revascularization of the culprit vessel by PCI as soon as possible in patients with ACS and cardiogenic shock, irrespective of time from symptom onset (Class I, Level B-R) 1, 2
- Treatment delays to primary PCI are associated with worse survival in patients with STEMI and hemodynamic instability 1, 2, 3
MCS Timing and Patient Selection
- The American College of Cardiology specifies that MCS is not a routine first-line intervention, and insertion of a microaxial intravascular flow pump (Impella) is reasonable to reduce death in selected patients with STEMI and severe or refractory cardiogenic shock (Class 2a) 1, 2
- Routine use of IABP or VA-ECMO is not recommended due to lack of survival benefit (Class 3) 1, 2
Clinical Algorithm for Decision-Making
- The American College of Cardiology recommends activating the catheterization laboratory immediately upon STEMI-CS diagnosis, and initiating vasopressors/inotropes as needed for hemodynamic support 1, 2, 4, 5
- Consider MCS insertion before PCI only if the patient has severe refractory shock, cardiac arrest requiring ongoing CPR, or profound hemodynamic collapse that precludes safe PCI performance 1, 2, 4, 5
- PCI of culprit vessel only is recommended, and multivessel PCI at time of primary PCI in cardiogenic shock is associated with higher rates of death or renal replacement therapy (Class 3: Harm) 1, 2, 3
Important Caveats and Pitfalls
- Delaying PCI to insert MCS device in all shock patients is a common pitfall, and routine MCS is not beneficial 1, 2
- Performing multivessel PCI during the index procedure increases mortality and renal failure 1, 3
- Using IABP routinely is not recommended, despite historical practice patterns, due to lack of survival benefit (Class 3) 1, 2