Cardiogenic shock after myocardial infarction — FFICM MCQ

Correct answer: E — Add an inotrope and discuss mechanical circulatory support

The correct answer is E, add an inotrope and discuss mechanical circulatory support. This man has established cardiogenic shock post anterior STEMI: MAP 58 mmHg despite escalating noradrenaline, oliguria, cool peripheries, lactate 6.1 mmol/L and echo confirming severe LV dysfunction without a mechanical cause. Vasopressor monotherapy is failing to restore perfusion because the primary problem is pump failure, not vasoplegia, so an inotrope (dobutamine or similar) is needed to augment contractility and cardiac output, and early liaison with a cardiogenic shock centre or cardiac surgery/cardiology for consideration of mechanical circulatory support (IABP, Impella, VA-ECMO) is appropriate when shock is refractory to medical therapy, consistent with NICE guidance on managing STEMI complicated by cardiogenic shock. Why the other options are wrong: C. Give 2 litres crystalloid rapidly: there is no evidence of hypovolaemia or fluid responsiveness here; aggressive fluid loading in severe LV failure risks worsening pulmonary oedema and gas exchange in an already compromised, ventilated patient. D. Stop noradrenaline and start labetalol: a beta-blocker is contraindicated in cardiogenic shock as it further depresses contractility and heart rate, worsening cardiac output and perfusion. A. Commence high-dose furosemide before perfusion improves: diuretics do not address the underlying low cardiac output state and may precipitate further hypotension and renal hypoperfusion before circulatory support is optimised. B. Target permissive hypotension to reduce afterload: this patient is already critically hypotensive with end-organ hypoperfusion (lactate 6.1, oliguria); deliberately tolerating lower pressures would worsen coronary and systemic perfusion, not help a shocked myocardium. Key point: Refractory cardiogenic shock with rising lactate despite vasopressors requires inotropic support and early escalation discussion for mechanical circulatory support rather than further fluid, diuretics, beta-blockade, or permissive hypotension.

Reference: NICE Guideline NG185, Acute coronary syndromes (2020, last reviewed 2026), section on management of STEMI and cardiogenic shock, www.nice.org.uk/guidance/ng185