p.46 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e816

the culprit vessel only is recommended.5,6 Emergency CABG is recommended in those patients in whom PCI is not feasible.2,9 Immediate revascularization with PCI or CABG is also recommended in high-risk patients with NSTEMI who are in cardiogenic shock.2–5 The use of MCS devices in patients with cardiogenic shock is covered in Section 8.2, “MCS in Patients With ACS and cardiogenic shock.”

Recommendation-Specific Supportive Text 1.	 In the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial,2 reported in 1999, patients with AMI and cardiogenic shock were randomized to medical therapy or emergency revascularization. Among the patients randomized to revascularization, 64% of patients were referred for PCI and 36% for CABG. The median time from randomization to revascularization was 0.9 hours for PCI and 2.7 hours for CABG. Despite lack of a significant difference in the primary endpoint of mortality at 30 days, emergency revascularization with either PCI or CABG reduced the mortality rate at 6 months,2 and the mortality benefit was maintained through 1 and 6 years.10,11 In an observational analysis from the FITT-STEMI (Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction) trial, for every 10-minute delay in PPCI after 60 minutes from FMC, there were an additional 3 to 4 deaths per 100 with a >80% mortality rate beyond 6 hours of delay from FMC.1 Therefore, it is recommended that PPCI should be performed in patients with STEMI and cardiogenic shock as soon as possible, ideally within 90 minutes, to reduce the mortality rate.1,2 Observational studies suggest that emergency CABG remains a treatment option in patients with cardiogenic shock who are not amenable to primary reperfusion with PCI3,4 or when PCI is unsuccessful.4,12

2 In patients with STEMI complicated by cardio-

genic shock and MVD, a strategy of multivessel PCI is associated with worse outcomes.5–7 The CULPRIT-SHOCK trial5 randomized 706 patients with AMI (approximately 60% with STEMI) and cardiogenic shock to a strategy of complete multivessel PCI or culprit-only PCI. At 30 days and 1 year, the rates of death or need for renal replacement therapy were significantly higher in the group of patients randomized to multivessel PCI.5,6 Importantly, the CULPRIT SHOCK trial permitted enrollment only if there was an identifiable culprit lesion. In situations where there is an unstable appearing nonculprit artery lesion, or in those patients with an uncertain culprit, the decision to proceed with multivessel PCI may be more nuanced.

8.2 MCS in Patients With ACS and Cardiogenic

Shock Recommendations for MCS in Patients With ACS and Cardiogenic Shock Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

2a B-R 1 In selected* patients with STEMI and severe or

refractory cardiogenic shock, insertion of a microaxial intravascular flow pump is reasonable to reduce death.1

2a B-NR 2.	 In patients with mechanical complication of ACS,

short-term MCS devices are reasonable for hemodynamic stabilization as a bridge to surgery.2–4

3: No benefit B-R 3 In patients with AMI and cardiogenic shock, the

routine use of intra-aortic balloon pump (IABP) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) is not recommended due to a lack of survival benefit.5–9

*See supportive text.

Synopsis Cardiogenic shock is estimated to occur in approximately 10% of patients with STEMI and is associated with an early mortality rate of 40% to 50%.10,11 Several types of devices for temporary MCS are available and have been studied in patients with cardiogenic shock with variable efficacy and increased risk of vascular complications. IABP counterpulsation improves coronary perfusion and reduces cardiac afterload. It is relatively easy to use and has a smaller insertion profile, which is associated with lower rates of vascular access site complications when compared with other MCS devices.12,13 Percutaneous microaxial flow pumps unload the LV by draining blood from the LV and pumping it to the ascending aorta. They are dependent on adequate right ventricular function to fill the LV and require adequate oxygenation of blood. VA-ECMO provides both blood flow and oxygenation but increases afterload. Randomized trials of MCS devices remain challenging to conduct due to relative lack of equipoise on the part of treating physicians, leading to selective patient enrollment and limiting the generalizability of study results. Although small studies of microaxial flow pumps did not demonstrate clinical benefit for patients with AMI and cardiogenic shock,14–16 a randomized trial at specialized centers in Europe demonstrated a mortality benefit with use of the microaxial flow pump in selected patients, albeit with increased risk of complications, including limb ischemia and renal replacement therapy.1 Best practices for insertion of all MCS devices, including the multimodality use of fluoroscopy and ultrasound, should be utilized when feasible for obtaining femoral access.17–19

Downloaded from http://ahajournals.org by on October 7, 2026