Management of Cardiogenic Shock

A 52 year old man with no known past medical history presents to the emergency department with 24 hours of chest pain, nausea and vomiting. An initial EKG shows a right bundle branch block (RBBB) and ST elevations in anterolateral leads (Fig. 9.1). He is given intravenous heparin, prasugrel and aspirin and taken directly to the cardiac catheterization lab. Coronary angiography reveals chronic appearing 100% right coronary artery (RCA) occlusion with left to right collateralization and 100% left anterior descending (LAD) artery occlusion. Two drug-eluting stents are placed into the LAD with restoration of TIMI 3 flow (see Table 9.1 for definition). Left ventriculogram reveals diffuse hypokinesis and a left ventricular end-diastolic pressure (LVEDP) of 30–35 mmHg. The patient is confused and not following commands. An intra-aortic balloon pump is placed. Arrangements are then made to transfer to tertiary care center for further management.