Saving the patient with post-ACS cardiogenic shock

The adoption of early revascularization as the preferred strategy in all ST-elevation myocardial infarctions (STEMI) and high risk acute coronary syndromes (ACS) without ST elevation resulted in a considerable reduction in the incidence of post-ACS cardiogenic shock (CS) however the incidence of CS on hospital arrival has not changed. In-hospital and 30 day mortality from CS remains excessively high in facilities with coronary revascularization capabilities. Trials investigating the incremental value of either intra-aortic counter-pulsation (IACP) or advanced MCS did not demonstrate a meaningful mortality reduction. Mortality remains 45-60% and depends on clinical characteristics of the patient, timely and successful revascularization and advanced MCS in suitable candidates. Most CS survivors demonstrate satisfactory functional capacity and quality of life. The authors propose the "Guthrie classification" for post-ACS CS. This classification promotes better characterization of CS patients enrolled in clinical trials and registries. It also allows the clinician to better define the goals and benefits of therapy for the CS subjects. The precise pathophysiology of post-ACS CS remains poorly understood at the biochemical and cellular level. Uncovering and modifying these processes remains key to any fundamental change in post-ACS CS outcomes.