Anterior STEMI complicated by cardiogenic shock — talk us through your management.

Question

A 62-year-old smoker presents to ED with 2 hours of central crushing chest pain radiating to his left arm. ECG shows 4mm ST elevation in V1–V4 with reciprocal change. He is clammy, mottled and oliguric. HR 108, BP 84/52, SpO₂ 92% on 4L, lactate 3.8, troponin rising. He is Killip class IV.

Accepted Answer

This is an anterior STEMI in cardiogenic shock — time-critical. ABCDE with simultaneous resuscitation and call for senior help. Airway patent. Breathing: titrate O₂ to 94–98%, consider non-invasive ventilation if pulmonary oedema. Circulation: two large-bore cannulae, continuous cardiac monitoring, 12-lead ECG repeated, bloods including troponin, lactate, U&E, FBC, clotting, group and save. I would give aspirin 300mg and a second antiplatelet (ticagrelor or prasugrel) per local pathway, analgesia with IV morphine plus antiemetic, and activate the primary PCI pathway aiming for door-to-balloon under 90 minutes. For cardiogenic shock I would avoid fluid loading, start noradrenaline early to maintain MAP ≥65, and add dobutamine if poor cardiac output. I would discuss mechanical circulatory support — IABP, Impella or VA-ECMO — with interventional cardiology and ITU as a bridge to recovery or revascularisation. Disability: GCS, glucose. Exposure: peripheries, signs of dissection. Throughout I would communicate clearly with the cath lab, ITU and the family, explaining honestly that this is a life-threatening heart attack with shock and that we are doing everything possible. Document in real time.

STEMI with cardiogenic shock

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