Cardiogenic shock due to myocardial infarction: diagnosis, monitoring and treatment: a German-Austrian S3 Guideline.

INTRODUCTION: Infarction-related cardiogenic shock (ICS) is usually due to left-ventricular pump failure. With a mortality of 30% to 80%, ICS is the most common cause of death from acute myocardial infarction. The S3 guideline presented here characterizes the current evidence-based treatment of ICS: early revascularization, treatment of shock, and intensive care treatment of multi-organ dysfunction syndrome (MODS) if it arises. The success or failure of treatment for MODS determines the outcome in ICS.
METHODS: Experts from eight German and Austrian specialty societies analyzed approximately 3600 publications that had been retrieved by a systematic literature search. Three interdisciplinary consensus conferences were held, resulting in the issuing of 111 recommendations and algorithms for this S3 guideline.
RESULTS: Early revascularization of the occluded vessel, usually with a percutaneous coronary intervention (PCI), is of paramount importance. The medical treatment of shock consists of dobutamine as the inotropic agent and norepinephrine as the vasopressor of choice and is guided by a combination of pressure and flow values, or by the cardiac power index. Levosimendan can be given in addition to treat catecholamine-resistant shock. For patients with ICS who are treated with PCI, the current S3 guideline differs from the European and American myocardial infarction guidelines with respect to the recommendation for intra-aortic balloon pulsation (IABP): Whereas the former guidelines give a class I recommendation for IABP, this S3 guideline states only that IABP "can" be used in this situation, in view of the poor state of the evidence. Only for patients being treated with systemic fibrinolysis is IABP weakly recommended (IABP "should" be used in such cases). With regard to the optimal intensive-care interventions for the prevention and treatment of MODS, recommendations are given concerning ventilation, nutrition, erythrocyte-concentrate transfusion, prevention of thrombosis and stress ulcers, follow-up care, and rehabilitation. DISCUSSION: The goal of this S3 guideline is to bring together the types of treatment for ICS that lie in the disciplines of cardiology and intensive-care medicine, as patients with ICS die not only of pump failure, but also (and even more frequently) of MODS. This is the first guideline that adequately emphasizes the significance of MODS as a determinant of the outcome of ICS.