BMC2-SHOCK- AMI-CS Best Practices

Version – August 17, 2026

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Introduction

Acute myocardial infarction cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. (Moller et al.) Early recognition and management are cornerstones of AMI-CS care- including hemodynamic stabilization with medical interventions, early revascularization, and use of temporary mechanical circulatory support (tMCS) in select patients. 

The recent DanGer-SHOCK trial demonstrated the value of early percutaneous left ventricular assist device (pVAD) placement with improved clinical outcomes (death at 180 days). However, pVAD was also associated with significant complications, including bleeding, vascular injury, bloodstream infections, and renal replacement therapy. (Moller et al.) In a real-world assessment of current clinical practice, there is significant variation in the care of AMI-CS patients with variable utilization of pulmonary arterial catheters, vasoactive agents and tMCS. (Cantey et al.) This study also identified that most interventional cardiologists, and thus care teams, had limited yearly experience treating patients with AMI-CS (average <1 case per year). Therefore, there is a need for improved standardization of care through the identification of best practices and protocol-based care. 

Early recognition is vital to the successful treatment of AMI-CS. The timing of CS onset following AMI is variable, but the SHOCK trial registry showed the median time from AMI symptoms to CS onset of 6 hrs. (Webb et al.) A comprehensive evaluation of non-invasive datapoints is important to the identification of AMI-CS, including vital signs (e.g. heart rate, blood pressure, oxygen saturation, use of vasoactive agents), echocardiographic factors (e.g., LV and RV function, valvular abnormalities, non-invasive filling pressures, mechanical complications), physical exam (e.g., mental status, peripheral perfusion, urine output), and laboratory evaluation (e.g., lactate, liver function tests, blood gases, basic metabolic panel). (Sinha et al.) Early invasive hemodynamics (e.g., pulmonary arterial catheter and/or left ventricular end-diastolic pressure assessment) is also important, as there is evidence that it may lead to earlier and more accurate identification of CS phenotyping to tailor medical and device-based therapies, with observational data indicating early PA catheter usage associated with improved mortality. (Tehrani et al., Kadosh et al., Garan et al.) 

The BMC2 Shock workgroup is a multidisciplinary group of physicians involved in the care of patients with AMI-CS, including emergency room physicians, cardiac intensivists, heart failure cardiologists, and interventional cardiologists.   The following document describes the best practices for the fundamental aspects of AMI-CS care- early recognition, early escalation, and early de-escalation. 

Best Practices: 

Early recognition

1. All providers involved in the management of AMI should maintain a high clinical suspicion for AMI-CS, taking into consideration patient-specific clinical, hemodynamic, and metabolic factors.
2. A lactate should be measured as part of the initial evaluation of all patients presenting with NSTEMI and STEMI.  For patients with elevated lactate levels, serial measurements (every 2-3 hours) should be obtained until normalization.
3. Early use of hemodynamic profiling is necessary to risk-stratify, phenotype, and guide treatment strategy for AMI-CS.  While pulmonary arterial catheterization is preferred for complete hemodynamic profiling, central venous catheter placement to obtain central venous pressures and mixed venous saturation, or echocardiography, may be considered based on local institutional experience.
4. Each institution should develop and actively refine site-specific protocols to enhance early recognition and early multidisciplinary collaboration amongst specialties (interventional cardiologists, cardiac surgeons, emergency medicine, and critical care) and care team members (physicians, nurses, radiation technologists, respiratory therapists) involved in the management of AMI-CS.

Early escalation and de-escalation

1. Early activation and involvement of a shock team, including interventional cardiology, cardiac surgery, advanced heart failure, and critical care, as able within hospital staffing availability, is critical for multi-disciplinary collaboration and management of AMI-CS patients.
2. Each site should have specific escalation protocols based on local site experience and resources for the management of temporary mechanical support options.  If a patient has exhausted the site’s resources during initial stabilization, consider early transfer to centers with advanced therapy capabilities, including ECMO, durable LVAD, and heart transplantation.
3. The multidisciplinary shock team should integrate the patient’s age, comorbidities, hemometabolic data, patient preferences, and overall goals of therapy (i.e., bridge to recovery, durable LVAD or transplant) into site-specific escalation and transfer protocols.
4. In the case of worsening hemodynamics and markers on end-organ perfusion, early protocol-based escalation should be based on local site protocols and resources. 
5. To mitigate the risks of temporary MCS and promote patient recovery, each site should have device-specific de-escalation protocols.
6. In the case of inability to wean from temporary MCS, early engagement with a site with advanced therapy capabilities is recommended.

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