1) Early revascularization through either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) improves survival rates in patients with cardiogenic shock compared to medical therapy alone. 2) There is ongoing debate about whether culprit vessel-only PCI or multivessel PCI is better for patients with cardiogenic shock and multivessel coronary artery disease. Current guidelines recommend culprit vessel PCI initially except in certain high-risk situations. 3) An integrated approach is needed using early revascularization, inotropic support, and potentially mechanical circulatory support, with involvement of multiple specialists. Cardiogenic shock continues to pose major challenges in acute cardiac care.

1. Revascularization
Strategies in
Management of
Cardiogenic shock
Prof. Christian JM Vrints

3. ESC 2014 Revasc guidelines: management of patients
with acute heart failure in the setting of ACS
S Windecker , P Kolh et al.
Eur Heart J (2014) 35, 2541–2619

4. The SHOCK Trial has been the most important study for
management guidelines in patients with cardiogenic shock
JS Hochman et al.
N Engl J Med 1999;341:625-34

5. Early Revascularization and
1 Year Survival-SHOCK trial
44
37
34
54
50
47
30 days 6 months 1 year
0
10
20
30
40
50
60
Survival %
Medical therapy
Revascularization
p=0.03p=0.11 p=0.03
• 13% absolute increase in 1 year
survival in patients assigned to
early revascularization
• number needed to treat of
<8 patients to save 1 life
JS Hochman et al.
JAMA. 2001;285:190-192

6. SHOCK trial: CABG vs. PCI
PCI (%) CABG (%) p-value
--------------------------------------------------------------------------
Diabetes 26.9 48.9 0.02
LMCA 13.0 41.3 0.001
3 vessel disease 60.3 80.4 0.03
coronary jeopardy score 7.1±3.2 9.9±2.3 0.0001
HD White et al.
Circulation. 2005;112:1992-2001.

7. Decreasing in-hospital mortality with increasing rates of early
PCI in patients with cardiogenic shock
STEMI registry Germany
U Zeymer et al.
ESC Congress Barcelona 2009

8. Ten-Year Trends in the Incidence and Treatment of
Cardiogenic Shock - AMIS Plus Registry
RV Jeger et al.
Ann Intern Med. 2008;149:618-626

9. SHOCK trial: 81% of the patients with
cardiogenic shock have multivessel disease
HD White et al.
Circulation. 2005;112:1992-2001.
How to treat:
–Culprit vessel PCI?
–Multivessel PCI?
• Immediate?
• Staged procedure?
–CABG?

10. What do the guidelines recommend?
• Approximately 50% of STEMI patients have significant
multivessel disease. Only the infarct-related artery
should be treated during the initial intervention. There is
no current evidence to support emergency intervention
in non-infarct-related lesions.
• The only exceptions, when multivessel PCI during acute
STEMI is justified, are in patients with cardiogenic shock
in the presence of multiple, truly critical (≥90%
diameter) stenoses or highly unstable lesions
(angiographic signs of possible thrombus or lesion
disruption), and if there is persistent ischaemia after PCI
of the supposed culprit lesion.
G. Steg, S James et al.
European Heart Journal (2012) 33, 2569–2619
ESC STEMI Guidelines 2012

11. SHOCK trial: most patients were treated
with single vessel PCI of the culprit lesion
HD White et al.
Circulation. 2005;112:1992-2001.
Multivessel disease 81%
PCI of infarct related
artery only
87%
Complete
revascularization
23%

12. STEMI with shock: Multivessel PCI
Advantages
• Improves:
• Peri-infarct blood flow
• Remote ischemia in perfusion
territory non–IRA
Disadvantages
• Clinical storm scenario
• Pro-thrombotic
• Pro-inflammatory
• PCI of non critical lesions
• Distal embolization
• No reflow
• More:
• Stents
• Contrast
• Radiation
Ischemia
LV
dysfunction
Hypotension
X

13. STEMI with MVD & cardiogenic shock:
culprit or multivessel PCI?
In hospital outcomes shock pts.
1 vessel
PCI
Multi-
vessel PCI
p
value
Patients 2654 433
Death 27.8% 36.5% <0.01
Death in
lab
2.7% 5.8% 0.25
Stroke 1.5% 2.6% 0.18
Bleeding 12.5% 13.8% 0.44
Renal
failure
7.1% 9.7% 0.03
Odds ratios mortality
National Cardiovascular Data Registry
MA Cavender et al.
Am J Cardiol 2009;104: 507-513
Multi- vs. 1-vessel PCI

14. Outcomes of Culprit Versus Multivessel PCI in Patients
With MVD Presenting With STEMI Complicated by Shock
Matthew A. Cavender et al.
J INVASIVE CARDIOL 2013;25(5):218-224
Patients undergoing MVPCI for STEMI-related shock are clinically different than those
treated with culprit PCI only; however, after risk adjustment both groups have similar
short- and long-term outcomes.
199 pts @ Cleveland Clinic 2002-2010

15. Outcomes of Multivessel PCI in Acute MI &
Cardiogenic Shock (EHS-PCI Registry)
T Bauer, U Zeymer et al.
Am J Cardiol 2012;109:941–946
determinants
for hospital mortality
*
*
*
336 pts
MV-PCI 24%

16. PPCI in STEMI with Resuscitated Cardiac Arrest,
and Cardiogenic Shock
D Mylotte et al.
J Am Coll Cardiol Intv 2013;6:115–25

17. Culprit-only vs. multivessel PCI in cardiogenic
shock complicating STEMI
Mortality MACE
JH Yang et al.
Crit Care Med 2014; 42:17–25

18. Culprit or multivessel revascularisation in
STEMI with cardiogenic shock
46.8
0.6 0.2 1.6
9.5
35.8
1.2 0.1
3.2 4.3
MACE before discharge
Death
Non-fatal M
I
Non-fatal Stroke
Bleeding
Dialysis
0
10
20
30
40
50
% Events
MV-PCI (n=173) Culprit-PCI (n=562)
German PCI registry (2008-2011)
735 patients with STEMI, cardiogenic shock & MVD
Multivessel PCI in 23,5%
U Zeymer et al.
Eurointervention 2015 In press.

19. Culprit or multivessel revascularisation in
STEMI with cardiogenic shock
Jin Sup Park et al.
Heart doi:10.1136/heartjnl-2014-307220. In press.
Korean Acute Myocardial
Infarction Registry (2006-
2012)
510 pts
Multivessel PCI in 24,3%

20. Conflicting results…
Trial N Mortality
multivessel
PCI, %
Mortality
culprit lesion
only PCI, %
Adjusted odds ratio
or hazard ratio
(95% CI)
Webb et al. 74 55 20 2.75 (1.05–7.25)
Cavender et al. 3087 36.5 27.8 1.5 (1.22–1.95)
Bauer et al. 336 48.8 37.4 1.28 (0.72–2.28)
Mylotte et al. 266 20.4 43.9 0.57 (0.38–0.84)
Yang et al. 338 35.0 30.6 1.06 (0.61–1.86)
Zeymer et al. 735 46.8 35.8 1.5 (1.15–1.84)
Park et al. 510 12.9 17.9 0.69 (0.40-1.19)

21. A RCT is underway!

22. Treatment Algorithm for Cardiogenic Shock
Acute MI & Cardiogenic Shock
Fluids for optimal preload
Vasopressors - Inotropes
Early Revascularization
1 – 2
vessel disease
Moderate
3 vessel disease
Left main
disease
Severe
3 vessel disease
PCI infarct related artery CABG
Acute multivessel PCI
Staged multivessel PCI
Staged CABG
MCS
HTX
Weaning
+-

23. Peripheral Perfusion 
LV-Dysfunction
systolic diastolic
Death
Hypoxia
LVEDP 
Lung edema
Cardiac Output 
Stroke volume 
Vasoconstriction
Fluid retention
Hypotension
Coronary-
perfusion 
Acute Myocardial Infarction
Reperfusion:
PCI/CABG
Ischemia
Mechanical
Support:
IABP/LVAD
Inotropes/
Vasopressors
Cardiogenic Shock Spiral
Thiele et al.
Eur Heart J 2010;31:1828-1835
Progressive
LV-Dysfunction

24. Peripheral Perfusion 
LV-Dysfunction
systolic diastolic
Death
Hypoxia
LVEDP 
Lung edema
Cardiac Output 
Stroke volume 
Vasoconstriction
Fluid retention
Hypotension
Coronary-
perfusion 
SIRS
eNOS
iNOS
NO 
Peroxynitrite 
IL-6 
TNF-α 
SVR 
Pro-Inflammation
Catecholamine sensitivity 
Contractility
Acute Myocardial Infarction
Reperfusion:
PCI/CABG
Ischemia
+
+
Mechanical
Support:
IABP/LVAD
Inotropes/
Vasopressors
+
+
Bleeding/
Transfusion
Cardiogenic Shock Spiral
Thiele et al.
Eur Heart J 2010;31:1828-1835
SIRS: Systemic Inflammatory Response Syndrome
Progressive
LV-Dysfunction

25. • An integrate approach is needed with:
– Early revascularization
– Inotropic support
– Mechanical support eventually as bridge to HTX
• Multidisciplinary collaboration needed by:
– Interventional cardiologists
– Cardiac surgeons
– Intensive acute cardiac care cardiologists
– Heart failure cardiologists
Cardiogenic shock remains a major
challenge in acute cardiac care