Cardiogenic Shock

Quick Answer

One-liner: Cardiogenic shock is acute cardiac pump failure causing inadequate tissue perfusion despite adequate intravascular volume, requiring immediate revascularization (if MI) and escalating haemodynamic support.

Cardiogenic shock occurs when the heart fails to pump sufficient blood to meet metabolic demands, resulting in systemic hypoperfusion and end-organ dysfunction. It carries 40-50% in-hospital mortality despite advances in mechanical circulatory support. The emergency physician's role is rapid recognition using the SCAI classification, initiation of haemodynamic support (inotropes/vasopressors), urgent cardiology consultation for early revascularization (if AMI), and consideration of mechanical support for refractory cases. Time to intervention directly correlates with survival.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Coronary artery anatomy, myocardial perfusion zones, cardiac conduction system, ventricular wall segments (AHA 17-segment model)
• Physiology: Frank-Starling mechanism, cardiac output determinants (preload, afterload, contractility, heart rate), systemic vascular resistance, baroreceptor response, renin-angiotensin-aldosterone axis activation
• Pharmacology: Inotropes (dobutamine, adrenaline, milrinone), vasopressors (noradrenaline), vasodilators (nitrates), antiplatelet agents (aspirin, P2Y12 inhibitors), mechanisms of action and adverse effects

Fellowship Exam Relevance

• Written: SCAI classification stages, indications for mechanical circulatory support, interpretation of haemodynamic parameters (cardiac index, PCWP), differential diagnosis of shock states, complications of acute MI
• OSCE: Resuscitation station with cardiogenic shock scenario, leading cardiac arrest team, interpreting bedside echocardiography, communicating with family about prognosis, initiating retrieval for tertiary interventions
• Key domains tested: Medical Expert (shock management), Communicator (family discussions), Leader (team coordination), Collaborator (cardiology/ICU liaison)

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Key Points

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Epidemiology

Australian/NZ Specific

• Incidence: Australian data from ANZACS-QI registry shows cardiogenic shock complicates 6-8% of STEMI presentations, with higher rates in rural/remote areas due to delayed presentation [8]
• Indigenous populations: Aboriginal and Torres Strait Islander peoples develop AMI 10-15 years earlier and have 2-3 times higher cardiovascular mortality, translating to increased cardiogenic shock burden [9]
• Rural/remote variations: Median time from symptom onset to PCI is 180 minutes in metropolitan centres vs 300+ minutes in remote areas, directly impacting shock development and outcomes [10]
• Retrieval burden: RFDS reports cardiogenic shock accounts for 8-12% of critical care retrievals, with one-way flight times exceeding 2-3 hours in Northern Territory and Western Australia [11]

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Pathophysiology

Mechanism

Cardiogenic shock results from a vicious cycle of cardiac dysfunction and systemic hypoperfusion:

Myocardial Injury (AMI/myocarditis/decompensation)
          ↓
Reduced Stroke Volume & Cardiac Output
          ↓
↓ Systemic Blood Pressure + ↓ Coronary Perfusion
          ↓
Compensatory Mechanisms Activated:
- Sympathetic surge (↑ HR, ↑ SVR)
- RAAS activation (fluid retention)
- Inflammatory cytokine release (SIRS)
          ↓
↑ Myocardial Oxygen Demand + ↑ Afterload
          ↓
Further Myocardial Ischaemia & Dysfunction
          ↓
SHOCK SPIRAL → Multi-Organ Failure

Key Pathophysiological Features

1. Primary Pump Failure: Loss of ≥40% of functional left ventricular myocardium (equivalent to cardiac index below 2.2 L/min/m²) [12]

2. Systemic Inflammatory Response: Release of TNF-α, IL-1, IL-6 creates "SIRS-like" state with peripheral vasodilation, capillary leak, and microcirculatory dysfunction [13]

3. Neurohumoral Activation: Catecholamine surge increases heart rate and SVR, but worsens myocardial oxygen supply-demand mismatch [14]

4. Diastolic Dysfunction: Elevated left ventricular end-diastolic pressure (LVEDP greater than 18 mmHg) and pulmonary capillary wedge pressure (PCWP greater than 15 mmHg) cause pulmonary oedema [15]

5. Microcirculatory Failure: Tissue hypoxia from inadequate oxygen delivery triggers anaerobic metabolism (lactate ≥2.0 mmol/L), acidosis, and cellular death [16]

Haemodynamic Criteria (Classical Definition)

Why It Matters Clinically

Understanding the shock spiral explains why:

• Early revascularization breaks the cycle by restoring coronary flow
• Inotropes increase contractility but risk worsening ischaemia (↑ O₂ demand)
• Vasopressors maintain coronary perfusion pressure but increase afterload
• Mechanical support unloads the ventricle and breaks the spiral when pharmacotherapy fails

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Clinical Approach

Recognition

Suspect cardiogenic shock in any patient with:

• Acute MI (especially anterior STEMI, inferior MI with RV involvement)
• Known heart failure presenting with acute decompensation
• Hypotension + signs of tissue hypoperfusion (altered mental status, oliguria, cold peripheries)
• Respiratory distress + cardiac history

SCAI Shock Classification (2022)

Essential for triage and prognostication:

Cardiac arrest modifier: Add subscript "A" (e.g., C_A) if patient suffered arrest — significantly worsens prognosis [17]

Initial Assessment

Primary Survey

• A (Airway): Patent? Stridor from pulmonary oedema? GCS below 8 requiring intubation?
• B (Breathing):
  • "Respiratory rate: Tachypnoea (greater than 25/min) indicates compensation"
  • "Oxygen saturation: Often normal initially, then deteriorates"
  • Auscultation: Bilateral crackles (pulmonary oedema), ± wheeze ("cardiac asthma")
  • "Work of breathing: Use of accessory muscles, inability to speak full sentences"
• C (Circulation):
  • "Heart rate: Tachycardia (greater than 100 bpm) or bradycardia (if conduction block)"
  • "Blood pressure: SBP below 90 mmHg or MAP below 65 mmHg"
  • "Pulse quality: Weak, thready peripheral pulses"
  • "Capillary refill: greater than 2 seconds, cool peripheries"
  • "JVP: Elevated (greater than 8 cm H₂O) indicates high filling pressures"
  • "Cardiac auscultation: S3 gallop (LV failure), murmurs (acute MR, VSR)"
• D (Disability):
  • "GCS: Confusion, agitation, or drowsiness from cerebral hypoperfusion"
  • "Pupils: Equal and reactive (unless anoxic brain injury)"
• E (Exposure):
  • "Skin: Cold, clammy, mottled (vs warm in distributive shock)"
  • "Peripheral oedema: Sacral/pedal oedema if chronic heart failure"

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Distress level: Sitting upright, unable to lie flat (orthopnoea), anxious facies
• Colour: Pale, cyanotic, or mottled skin
• Diaphoresis: Profuse sweating (sympathetic activation)
• Respiratory pattern: Tachypnoea, use of accessory muscles

Specific Findings

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

RUSH Protocol (Rapid Ultrasound in Shock) [18]:

1. Cardiac Views:

   • Parasternal long-axis: LV size, wall motion, EF estimation
   • Apical 4-chamber: Global LV function, RV size (RV:LV greater than 1.0 suggests RV strain)
   • Subcostal: Pericardial effusion (tamponade), IVC assessment

2. IVC Assessment:

   • Cardiogenic shock: IVC greater than 2.1 cm diameter, below 50% collapsibility (high CVP, congestion)
   • Hypovolaemic shock: IVC below 1.5 cm, greater than 50% collapsibility (low CVP, empty tank)

3. Lung Ultrasound:

   • B-lines (≥3 per intercostal space, bilateral): Pulmonary oedema (PCWP greater than 18 mmHg)
   • Pleural effusions: Bilateral in chronic heart failure

4. Key Findings in Cardiogenic Shock:

   • Severe global LV hypokinesis (EF below 30-40%)
   • Dilated LV with poor systolic function
   • Plethoric IVC (greater than 2.1 cm, minimal variation)
   • Diffuse B-lines (interstitial oedema)

Limitations: Operator-dependent, poor windows in obese/emphysema patients, cannot replace formal echocardiography [19]

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Management

Immediate Management (First 10 Minutes)

1. Call for senior help + Cardiology consult immediately (0 min)
2. High-flow oxygen 15L via non-rebreather (target SpO₂ ≥94%) (1 min)
3. Large-bore IV access x 2, draw bloods (VBG with lactate, troponin, FBC, UEC) (2 min)
4. Continuous monitoring: ECG, NIBP (or arterial line), SpO₂, urine output (3 min)
5. 12-lead ECG (identify STEMI/NSTEMI) (4 min)
6. Aspirin 300 mg PO (if AMI suspected, no contraindication) (5 min)
7. POCUS cardiac + IVC assessment (confirm cardiogenic cause) (6 min)
8. Commence inotrope/vasopressor (noradrenaline/dobutamine) via central line or large peripheral (7 min)
9. Consider CPAP/BiPAP if pulmonary oedema + work of breathing (avoid if SBP below 90) (8 min)
10. Activate catheterization lab if STEMI (target door-to-balloon below 90 min) (10 min)

Resuscitation

Airway

• Indications for intubation:

  • GCS ≤8 (inability to protect airway)
  • Refractory hypoxia despite CPAP/BiPAP (PaO₂ below 60 mmHg on high-flow O₂)
  • Impending respiratory arrest (exhaustion, bradypnoea)
  • Cardiac arrest

• Intubation considerations:

  • "Pre-oxygenation: 100% FiO₂, consider CPAP pre-oxygenation"
  • "Induction agents: Avoid propofol/thiopentone (myocardial depression, vasodilation). Use ketamine 1-1.5 mg/kg IV (maintains BP) or etomidate 0.2-0.3 mg/kg IV (haemodynamically neutral)"
  • "Muscle relaxant: Rocuronium 1.0-1.2 mg/kg IV (RSI)"
  • "Post-intubation hypotension: Common due to loss of sympathetic drive + positive pressure ventilation. Have vasopressor boluses ready (metaraminol 0.5 mg IV or phenylephrine 100 mcg IV)"

Breathing

• Oxygen targets: SpO₂ 94-98% (avoid hyperoxia, may increase infarct size) [20]

• Non-invasive ventilation:

  • "CPAP 5-10 cmH₂O: Reduces preload, improves oxygenation in pulmonary oedema"
  • "Contraindications: SBP below 90 mmHg (relative), vomiting, facial trauma, unable to protect airway"
  • "Evidence: Reduces intubation rate (NNT 13) but no mortality benefit [21]"

• Mechanical ventilation (if intubated):

  • "Tidal volume: 6-8 mL/kg ideal body weight (lung-protective)"
  • "PEEP: 5-10 cmH₂O (improves oxygenation, but excessive PEEP reduces venous return)"
  • "FiO₂: Wean to maintain SpO₂ 94-98%"
  • "Monitor: Positive pressure ventilation reduces venous return and can worsen hypotension"

Circulation

Haemodynamic Targets:

• MAP ≥65 mmHg (higher if chronic hypertension: MAP ≥75-80 mmHg)
• Lactate clearance ≥10% per hour
• Urine output ≥0.5 mL/kg/h
• Improved mental status

Fluid Strategy:

Medications

Vasopressors & Inotropes

First-Line: Noradrenaline + Dobutamine Combination

Evidence:

• SOAP II Trial: Noradrenaline superior to dopamine in cardiogenic shock (lower arrhythmia rate, trend to lower mortality) [22]
• OptimaCC Trial: Adrenaline vs noradrenaline — adrenaline caused more refractory shock and lactic acidosis [23]
• DOREMI Trial: Dobutamine vs milrinone — no difference in composite outcome (death/arrest/transplant/MCS) [24]

Second-Line Agents:

Diuretics

Antiplatelet & Anticoagulation (if AMI-related)

Paediatric Dosing

Cardiogenic shock in children is rare; causes differ (congenital heart disease, myocarditis, cardiomyopathy)

Definitive Care

Early Revascularization (AMI-Related Cardiogenic Shock)

SHOCK Trial (1999): Early revascularization (PCI or CABG within 6 hours) vs initial medical stabilization [26]

• 30-day mortality: 46.7% (revascularization) vs 56.0% (medical) — not statistically significant (p=0.11)
• 6-month mortality: 50.3% vs 63.1% — statistically significant (p=0.027), NNT=8
• Recommendation: Emergency PCI/CABG within 6 hours for all AMI-related cardiogenic shock (Class I, AHA/ESC guidelines)

Culprit Vessel Only vs Complete Revascularization:

• CULPRIT-SHOCK trial (2017): Culprit-lesion-only PCI vs multivessel PCI in STEMI + cardiogenic shock [27]
• Result: Culprit-only approach reduced 30-day death/renal failure (45.9% vs 55.4%, p=0.01)
• Recommendation: Treat culprit vessel only; stage complete revascularization later

Mechanical Circulatory Support (MCS)

Indications: SCAI stage D-E shock despite escalating inotropes/vasopressors, with:

• Reversible cardiac pathology (AMI, myocarditis, post-cardiotomy)
• Age and comorbidities compatible with meaningful recovery
• No contraindications (severe aortic regurgitation for Impella, peripheral vascular disease for IABP/femoral access)

Options:

Evidence:

• IABP-SHOCK II (2012): Routine IABP in AMI + cardiogenic shock showed no mortality benefit (39.7% vs 41.3%, p=0.69) [28]

  • "Recommendation: IABP NOT routinely recommended (Class III, ESC). Reserved for mechanical complications (VSR, acute MR) as bridge to surgery"

• Impella: No completed RCTs vs medical therapy. DanGer Shock trial (2024) comparing Impella CP to standard care in AMI + shock showed no 6-month mortality benefit (45.8% vs 46.6%, p=0.89) [29]

• VA-ECMO: Observational data suggests survival 20-40% in cardiogenic shock. Use as bridge to recovery (myocarditis, post-MI stunning) or bridge to decision (transplant evaluation) [30]

Australian/NZ MCS Centres:

• NSW: RPA, St Vincent's, Prince of Wales
• VIC: Alfred, Austin, Monash
• QLD: Prince Charles, Gold Coast
• SA: Royal Adelaide
• WA: Fiona Stanley
• NZ: Auckland City, Christchurch

Retrieval for MCS: Contact state ECMO services:

• NSW: ECLS Service 1800 650 004
• VIC: VECMOS 1300 368 661
• QLD: Adult Retrieval Services 1300 799 127

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Disposition

Admission Criteria

All patients with cardiogenic shock require ICU/CCU admission:

• Continuous haemodynamic monitoring (arterial line, central venous access)
• Vasopressor/inotrope titration
• Serial lactate monitoring (every 2-4 hours)
• Cardiology/interventional cardiology input
• Consider transfer to tertiary centre if mechanical support anticipated

ICU/HDU Criteria

Mandatory ICU admission:

• SCAI stage C-E shock (requiring vasopressors/inotropes)
• Post-PCI/post-CABG cardiogenic shock
• Mechanical ventilation
• Multi-organ failure (AKI, shock liver, ARDS)
• Mechanical circulatory support (IABP, Impella, VA-ECMO)
• Haemodynamic instability requiring invasive monitoring (PA catheter)

Inter-Hospital Transfer Criteria

Transfer to tertiary PCI-capable centre:

• STEMI with cardiogenic shock requiring primary PCI (emergency transfer, accompany with doctor/RN, vasopressors running)
• SCAI stage D-E shock requiring mechanical circulatory support
• Mechanical complications (VSR, free wall rupture, papillary muscle rupture) requiring cardiac surgery
• Refractory shock despite maximal inotropes/vasopressors

Pre-Transfer Checklist:

1. Senior discussion with receiving cardiologist/intensivist
2. Stabilise haemodynamics as much as possible (target MAP ≥65 mmHg, lactate trending down)
3. Secure airway if GCS ≤8 or anticipated deterioration
4. Adequate IV access (2x large-bore peripheral + central line if time permits)
5. Continuous monitoring during transfer (portable monitor, transport ventilator if intubated)
6. Vasopressor infusion via syringe driver (noradrenaline 1 mg in 50 mL saline, run at appropriate rate)
7. Transfer team: Doctor (FACEM or advanced trainee) + Critical Care Paramedic or RN
8. Notify receiving hospital ETA, patient status

Follow-up

Post-Discharge (if patient survives to discharge):

• Cardiology outpatient review within 2 weeks
• Cardiac rehabilitation referral
• Echocardiography at 6-8 weeks (assess recovery of LV function)
• Optimal medical therapy: Dual antiplatelet (12 months post-PCI), beta-blocker, ACE-inhibitor, statin, diuretics as needed
• Consider ICD implantation if EF remains below 35% at 3 months post-MI [31]
• Psychosocial support (high rates of PTSD, depression post-critical illness)

GP Letter Must Include:

• Diagnosis: Cardiogenic shock secondary to [AMI/myocarditis/decompensated HF]
• SCAI stage on presentation
• Interventions performed (PCI vessels, mechanical support used)
• Current medications and rationale
• Follow-up plan (cardiology, echocardiography)
• Red flags to return: Recurrent chest pain, dyspnoea, syncope, oedema

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Special Populations

Paediatric Considerations

Cardiogenic shock in children is rare; main causes differ from adults:

• Congenital heart disease: Ductal-dependent lesions (HLHS, critical coarctation), post-surgical
• Myocarditis: Viral (enterovirus, adenovirus), autoimmune
• Cardiomyopathy: Dilated, hypertrophic, restrictive
• Arrhythmias: SVT, complete heart block

Differences in Management:

• Fluid boluses: Unlike adults, children often benefit from 10-20 mL/kg crystalloid bolus (higher physiological reserve)
• Inotrope choice: Adrenaline is first-line (0.05-1 mcg/kg/min), whereas adults prefer noradrenaline + dobutamine
• Mechanical support: Pediatric ECMO cannulae and pumps required; early discussion with pediatric cardiac centre
• Oxygen delivery: Children have higher metabolic rate; target SpO₂ 94-98% (neonates 90-95% if ductal-dependent lesion)

Pregnancy

Peripartum cardiomyopathy can present as cardiogenic shock in late pregnancy or post-partum:

• Presentation: Heart failure symptoms in last month of pregnancy or within 5 months post-partum
• Diagnosis: Echocardiography showing LV systolic dysfunction (EF below 45%) without other cause
• Management:
  • Avoid ACE-inhibitors/ARBs in pregnancy (teratogenic); use hydralazine + nitrates for afterload reduction
  • "Bromocriptine: Emerging evidence for blocking prolactin in peripartum cardiomyopathy (2.5 mg BD for 2 weeks, then 2.5 mg daily for 6 weeks) [32]"
  • "Delivery: Expedite if fetus viable and mother deteriorating"
  • "Anticoagulation: Consider LMWH if EF below 35% (high thrombotic risk)"
  • "Mechanical support: VA-ECMO can be used if refractory shock; case series show maternal survival 60-80%"

Obstetric Consultation: Mandatory for all pregnant patients with cardiogenic shock

Elderly

Considerations in older adults (greater than 75 years):

• Higher mortality: SHOCK trial subgroup showed no clear benefit of revascularization in ≥75 years, though sample size small [26]
• Comorbidities: CKD, COPD, frailty affect MCS candidacy
• Polypharmacy: Beta-blockers, CCBs may mask compensatory tachycardia
• Cognitive impairment: Difficulties with consent for PCI/MCS
• Goals of care: Early discussion with family about prognosis (40-50% mortality), ceilings of treatment, resuscitation status

Shared Decision-Making: Engage geriatrician or palliative care if patient/family considering comfort-focused care

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Epidemiology:

• Aboriginal and Torres Strait Islander peoples experience acute MI 10-15 years earlier than non-Indigenous Australians, with 2-3 times higher cardiovascular mortality [9]
• Māori have 40-50% higher rates of ischaemic heart disease and present with AMI at younger ages (median 10 years earlier) [33]
• Higher prevalence of risk factors: diabetes (3-4x), smoking (2x), hypertension, chronic kidney disease

Barriers to Care:

• Geographic isolation: Many remote communities are 200-500 km from PCI-capable centres
• Cultural safety: Mistrust of healthcare system due to historical trauma, racism
• Communication: Language barriers, need for Aboriginal Health Workers or cultural liaison
• Access: Transport costs, lack of family support if transferred to distant tertiary centre
• Health literacy: Lower awareness of AMI symptoms, reluctance to seek care

Specific Actions:

1. Early retrieval: Lower threshold for RFDS retrieval given transport distances
2. Cultural liaison: Involve Aboriginal Health Worker or Torres Strait Islander Health Worker in care discussions
3. Interpreter services: Use qualified medical interpreters (not family members) for consent discussions
4. Family involvement: Recognize importance of extended family in decision-making; allow flexibility in visiting hours
5. Discharge planning: Engage Aboriginal Community Controlled Health Organisation (ACCHO) for follow-up in community
6. Culturally appropriate communication:
   • Avoid direct eye contact if culturally inappropriate
   • Allow time for discussion and questions
   • Explain procedures clearly without medical jargon
   • Acknowledge spiritual/cultural beliefs (e.g., sorry business after death)

Māori-Specific Considerations:

• Whānau involvement: Family-centred decision-making is paramount
• Tikanga protocols: Respect for cultural practices, karakia (prayer)
• Manaakitanga: Providing hospitality and care in culturally appropriate manner
• Health inequity: Acknowledge systemic barriers and advocate for equitable access to PCI/MCS

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Acute Management of Cardiogenic Shock

Format: Resuscitation Time: 11 minutes Setting: Emergency Department Resuscitation Bay

Candidate Instructions:

You are the ED registrar. A 65-year-old man has just been brought in by ambulance with chest pain and shortness of breath. He is alert but appears unwell. The nurse reports BP 85/55 mmHg, HR 115 bpm, RR 28/min, SpO₂ 90% on room air.

Your task is to perform an initial assessment and commence management. You have a nurse to assist you. The examiner will provide clinical information as you request it.

Examiner Instructions: Patient is in cardiogenic shock secondary to anterior STEMI. Provide findings as candidate requests:

• History: 3 hours crushing central chest pain, radiating to left arm, sweating, nausea
• Examination: Cold, clammy, confused (GCS 14/15), elevated JVP, S3 gallop, bilateral basal crackles, weak peripheral pulses
• ECG: 3-4 mm STE in V2-V5, reciprocal STD in III/aVF
• VBG: pH 7.28, lactate 3.5 mmol/L, HCO₃⁻ 18
• POCUS: Severe anterior wall hypokinesis, EF ~25%, plethoric IVC greater than 2.1 cm
• Response to interventions: BP improves to 92/60 with noradrenaline, SpO₂ 95% on high-flow oxygen

Award marks for:

• Systematic ABCDE approach
• Early recognition of cardiogenic shock
• Appropriate investigations ordered
• Correct pharmacotherapy (vasopressors, DAPT, avoiding fluids)
• Early cardiology referral for PCI

Actor/Patient Brief: You are a 65-year-old man with severe chest pain for 3 hours. You feel very unwell, sweaty, and short of breath. You can answer questions but are quite confused and anxious. You have no significant medical history.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Recognizes cardiogenic shock (not just "hypotension")
  • Avoids fluid boluses (common error)
  • Calls cardiology early for PCI (not after "stabilizing")
  • Starts appropriate vasopressor/inotrope combination

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Station 2: Communication - Discussing Prognosis in Cardiogenic Shock

Format: Communication Time: 11 minutes Setting: ED Relatives' Room

Candidate Instructions:

You are the ED consultant. A 70-year-old man was admitted 6 hours ago with cardiogenic shock secondary to anterior STEMI. He underwent emergency PCI (LAD stented) but remains in SCAI stage D shock despite escalating doses of noradrenaline (0.4 mcg/kg/min) and dobutamine (15 mcg/kg/min). Lactate is 5.5 mmol/L (up from 4.0 post-PCI). The cardiology team has offered mechanical circulatory support (VA-ECMO or Impella) but emphasize the high mortality risk (60-70% even with support). His daughter has arrived and wants to speak with you.

Your task is to update her on his condition, explain the treatment options, and explore her understanding of his wishes regarding escalation of care.

Examiner Instructions: Daughter (aged 45) is anxious and tearful. She lives interstate and last saw her father 3 months ago when he was well. She is aware he had a "heart attack" but does not understand the severity. She will ask:

• "Is he going to be okay?"
• "What is ECMO? Is it risky?"
• "What would you do if it was your father?"

Award marks for empathy, clear explanation, shared decision-making, and exploring patient's values.

Actor/Patient Brief: You are the 45-year-old daughter of the patient. You are shocked and scared. You last spoke to your father 2 days ago and he seemed fine. You know he has high blood pressure and takes "some tablets" but nothing serious. You do not know his wishes regarding life support. You want "everything done" initially but may reconsider if you understand the poor prognosis. You will cry at times during the conversation.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Delivers bad news sensitively (not blunt "he's dying")
  • Avoids medical jargon or explains it clearly
  • Explores patient's values (not just "what do you want?")
  • Doesn't pressure family or say "what I would do"

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Station 3: POCUS Interpretation in Shock

Format: Clinical Skill/Interpretation Time: 11 minutes Setting: ED Clinical Skills Area

Candidate Instructions:

You are the ED registrar. You have been asked to review a 58-year-old woman with undifferentiated shock (BP 80/50 mmHg, HR 120 bpm, lactate 4.0 mmol/L). A colleague has performed a POCUS RUSH exam and saved the clips. Review the cardiac, IVC, and lung ultrasound images provided, and present your findings and differential diagnosis to the examiner.

Examiner Instructions: Provide candidate with 4 ultrasound video clips (printed stills acceptable):

1. Parasternal long-axis: Severely hypokinetic LV, dilated LV, EF ~20-25%
2. Apical 4-chamber: Global LV dysfunction, normal RV size, no pericardial effusion
3. IVC subcostal: Dilated IVC 2.5 cm, minimal respiratory variation (below 30%)
4. **Lung (anterior): Bilateral multiple B-lines (greater than 3 per rib space)

Expected candidate response:

• Severe LV systolic dysfunction (EF 20-25%)
• High filling pressures (dilated IVC, minimal variation → high CVP)
• Pulmonary oedema (B-lines)
• Diagnosis: Cardiogenic shock (likely acute decompensated heart failure or AMI)

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Correctly identifies severe LV dysfunction (not just "reduced EF")
  • Interprets IVC correctly (dilated, non-collapsing = high CVP = cardiogenic)
  • Integrates findings into a coherent diagnosis, not just describes clips

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SAQ Practice

Question 1 (8 marks, 8 minutes)

Stem: A 62-year-old man presents with anterior STEMI complicated by cardiogenic shock. He has undergone emergency PCI with LAD stenting. Despite noradrenaline 0.3 mcg/kg/min and dobutamine 10 mcg/kg/min, he remains hypotensive (BP 78/50 mmHg) with lactate 4.5 mmol/L.

Question: List FOUR indications for considering mechanical circulatory support in this patient. (4 marks)

Model Answer:

1. SCAI stage D shock — Failure to respond to escalating vasopressor/inotrope therapy (or requiring increasing doses after initial improvement) (1 mark)
2. Persistent hypoperfusion — Lactate ≥4.0 mmol/L not clearing despite revascularization and pharmacological support (1 mark)
3. Worsening end-organ dysfunction — Progressive acute kidney injury (rising creatinine, oliguria), shock liver (rising transaminases), or cerebral hypoperfusion (declining GCS) (1 mark)
4. Reversible cardiac pathology — Acute MI with potentially viable myocardium (stunned myocardium that may recover with temporary support) (1 mark)

Examiner Notes:

• Accept: "Escalating vasopressor requirements," "High lactate not improving," "Multi-organ failure," "Bridge to recovery"
• Do not accept: "Low blood pressure" alone (too vague), "Patient looks unwell" (not specific), "Cardiologist requested it" (not a clinical indication)

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Question 2 (6 marks, 6 minutes)

Stem: You are managing a patient with cardiogenic shock in a rural ED. The nearest PCI-capable hospital is 300 km away (3-hour road transfer).

Question: Outline your approach to stabilization and retrieval of this patient. (6 marks)

Model Answer:

Immediate Stabilization (3 marks):

1. Airway management — Early intubation if GCS ≤8, refractory hypoxia, or anticipated deterioration during transfer. Use ketamine or etomidate (avoid propofol). Ensure secure ETT and portable ventilator with adequate oxygen supply (1 mark)
2. Haemodynamic support — Commence vasopressor/inotrope via large peripheral vein or central line if time permits. Prepare infusions for transport (noradrenaline 1 mg in 50 mL saline via syringe driver). Target MAP ≥65 mmHg (1 mark)
3. Investigations/monitoring — 12-lead ECG, VBG with lactate, arterial line (if skilled), continuous ECG/NIBP/SpO₂ monitoring during transfer. Urinary catheter for hourly urine output (1 mark)

Retrieval Coordination (3 marks): 4. Early contact — Call receiving cardiologist/intensivist immediately (not after "stabilization"). Discuss STEMI management (thrombolysis vs transfer for PCI), MCS candidacy (1 mark) 5. Retrieval service — Contact RFDS or road retrieval service (doctor + critical care paramedic/RN). Provide clinical summary, vital signs, vasopressor doses, airway status (1 mark) 6. Consider thrombolysis — If PCI not available within 120 minutes and patient has STEMI, give fibrinolysis (tenecteplase weight-based) before/during transfer. Post-CPR is relative contraindication but benefit outweighs risk in STEMI + shock (1 mark)

Examiner Notes:

• Accept: "Secure airway," "Vasopressors running," "RFDS retrieval," "Thrombolysis if PCI delayed"
• Do not accept: "Give fluids" (worsens pulmonary oedema), "Wait for patient to stabilize" (delays definitive care), "Transfer without doctor" (too unstable)

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Question 3 (8 marks, 8 minutes)

Stem: A 68-year-old woman with inferior STEMI develops cardiogenic shock. Her BP is 75/50 mmHg, JVP is elevated, and lung fields are clear. Right-sided ECG shows 2 mm ST elevation in V₄R.

Question: (a) What is the diagnosis? (1 mark) (b) Explain the pathophysiology causing hypotension. (3 marks) (c) Outline your initial management. (4 marks)

Model Answer:

(a) Diagnosis (1 mark):

• Right ventricular infarction (1 mark)

(b) Pathophysiology (3 marks):

1. RV systolic failure — Infarction of RV free wall (usually from proximal RCA occlusion) causes reduced RV contractility and stroke volume (1 mark)
2. Reduced LV preload — The failing RV cannot pump adequate blood into the pulmonary circulation, reducing LV filling (preload-dependent state) (1 mark)
3. Hypotension — Low LV preload results in reduced LV stroke volume and cardiac output, causing systemic hypotension despite preserved LV function (1 mark)

(c) Management (4 marks):

1. IV fluid resuscitation — Give 250-500 mL 0.9% saline boluses to augment RV preload. Reassess BP and JVP after each bolus. May need 1-2L total (1 mark)
2. Avoid preload-reducing agents — Do NOT give nitrates, diuretics, or morphine (all reduce preload and worsen hypotension) (1 mark)
3. Treat bradycardia — If heart rate below 60 bpm with hypotension, give atropine 600 mcg IV. Consider temporary pacing if high-grade AV block develops (RCA supplies AV node) (1 mark)
4. Urgent revascularization — Emergency PCI of RCA to restore RV perfusion. RV infarction has 25-30% mortality if not revascularized (1 mark)

Examiner Notes:

• Accept: "RV MI," "Give fluids," "Avoid nitrates," "Emergency PCI"
• Do not accept: "LV infarction" (clear lung fields rule out LV failure), "Give diuretics" (contraindicated), "Delay PCI" (time-critical)
• Common mistake: Not recognizing RV infarction and treating as LV failure (giving diuretics/nitrates worsens shock)

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Question 4 (6 marks, 6 minutes)

Stem: Compare and contrast the IABP and Impella mechanical circulatory support devices.

Question: Complete the table below comparing IABP and Impella.

Model Answer:

Examiner Notes:

• Accept: "Balloon inflation/deflation," "Axial pump LV to aorta," "0.5 L/min," "2.5-5.5 L/min," "IABP-SHOCK II no benefit," "No RCT benefit for Impella"
• Do not accept: "IABP pumps blood" (it augments, doesn't pump), "Impella proven to save lives" (no RCT evidence yet)
• Award partial marks for incomplete but correct statements

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Australian Guidelines

ARC/ANZCOR

• ANZCOR Guideline 11.7: Acute Coronary Syndromes [37]

  • Recommends early revascularization (PCI or CABG) for AMI-related cardiogenic shock (Class I)
  • Target door-to-balloon time below 90 minutes for STEMI with cardiogenic shock (though often exceeded due to stabilization needs)
  • Emphasizes culprit-vessel-only PCI strategy (based on CULPRIT-SHOCK trial)
  • Notes IABP not routinely recommended (Class III) based on IABP-SHOCK II

• ANZCOR Guideline 11.4: Reperfusion Strategy [38]

  • If PCI not available within 120 minutes, consider fibrinolysis for STEMI + cardiogenic shock (tenecteplase weight-based dosing)
  • Post-thrombolysis transfer to PCI centre for rescue PCI if failed reperfusion or routine angiography within 3-24 hours

• Key differences from AHA/ERC:

  • Australian guidelines place greater emphasis on retrieval medicine and fibrinolysis (due to geographic isolation)
  • RFDS protocols integrated into cardiogenic shock management pathways in rural/remote areas
  • Specific mention of Aboriginal and Torres Strait Islander health disparities and cultural safety

Therapeutic Guidelines Australia

• Cardiovascular (eTG complete) [39]:

  • "Cardiogenic shock pharmacotherapy: Noradrenaline + dobutamine first-line (consistent with international guidelines)"
  • Avoid adrenaline as first-line (increases lactate, arrhythmia risk)
  • Milrinone is alternative to dobutamine but requires caution due to hypotension risk and long half-life
  • Frusemide only after haemodynamic stabilization (not in acute phase)

• Cardiac reperfusion:

  • Aspirin 300 mg + ticagrelor 180 mg (or prasugrel 60 mg if below 75 years, greater than 60 kg)
  • Unfractionated heparin for PCI (60 U/kg bolus, 12 U/kg/h infusion)
  • Glycoprotein IIb/IIIa inhibitors (eptifibatide, tirofiban) reserved for high-risk PCI, not routine

State-Specific Protocols

• NSW Health: Cardiogenic Shock Pathway [40]:

  • Mandates early cardiology referral within 30 minutes of SCAI C shock recognition
  • Transfer pathways to tertiary centres (RPA, St Vincent's, Prince of Wales) for MCS
  • "ECLS (extracorporeal life support) retrieval service: 1800 650 004 (24/7)"

• Victoria: Cardiac Clinical Network [41]:

  • "STEMI + cardiogenic shock: Direct ambulance bypass to PCI-capable centre (Alfred, Austin, Box Hill, Monash)"
  • "VECMOS retrieval for VA-ECMO: 1300 368 661"
  • Impella available at Alfred, MonashHeart (limited stock, cardiology approval required)

• Queensland: Cardiac Network [42]:

  • "Primary PCI hubs: Prince Charles, Royal Brisbane, Gold Coast, Townsville"
  • RFDS retrieval protocols for Far North Queensland and outback areas
  • Telemedicine cardiology consultation available 24/7 for rural/remote EDs

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Remote/Rural Considerations

Pre-Hospital

Ambulance Management:

• Recognition: Paramedics should identify cardiogenic shock (hypotension + pulmonary oedema, or hypotension + clear lungs if RV infarction)
• 12-lead ECG: Performed in field, transmitted to receiving hospital to activate cath lab
• Destination: Bypass to PCI-capable centre if STEMI + shock, even if further distance (time to revascularization is critical)
• Management en route: High-flow oxygen, IV access, DAPT (aspirin ± ticagrelor if protocol allows), avoid fluid boluses unless RV infarction suspected

RFDS Retrieval:

• Contact RFDS coordination centre as soon as cardiogenic shock recognized
• Provide clinical summary: Age, STEMI location, SCAI stage, vasopressor requirements, airway status
• Expect 1-4 hour mobilization time depending on aircraft availability and distance
• Patient may deteriorate significantly during wait — prepare for intubation, escalating vasopressors

Resource-Limited Setting

Modified Approach When Resources Limited:

1. Haemodynamic monitoring:

   • If no arterial line: Use frequent NIBP (every 5 min), manual pulse checks
   • If no central line: Give vasopressors via large-bore peripheral (18G or larger in ACF). Risk of extravasation, but acceptable short-term if no other option
   • Lactate: If no VBG machine, use capillary lactate meter (less accurate but better than nothing)

2. Vasopressor/inotrope access:

   • Peripheral noradrenaline: Safe for below 12-24 hours if large vein, well-diluted (e.g., 4 mg in 250 mL = 16 mcg/mL). Monitor insertion site hourly for extravasation
   • Adrenaline IM: If no IV access and patient deteriorating, give adrenaline 0.5 mg IM every 5 min (off-label, but may temporize until IV access obtained)

3. Ventilation:

   • If no ventilator: Bag-valve-mask with PEEP valve (5-10 cmH₂O). Labor-intensive but feasible for 1-2 hours during retrieval wait
   • If no CPAP machine: DIY CPAP using BVM + PEEP valve + tight-fitting mask (not ideal but may reduce intubation need)

4. Thrombolysis:

   • Low threshold for fibrinolysis if PCI not available within 120 minutes
   • Tenecteplase preferred (single bolus, weight-based): 30 mg if below 60 kg, 35 mg if 60-69 kg, 40 mg if 70-79 kg, 45 mg if 80-89 kg, 50 mg if ≥90 kg
   • Post-thrombolysis: Arrange transfer for angiography ± rescue PCI

Retrieval

Criteria for Urgent Retrieval:

• STEMI + cardiogenic shock requiring PCI (if local hospital not PCI-capable)
• SCAI stage D-E shock requiring mechanical circulatory support (only available at tertiary centres)
• Mechanical complications (VSR, free wall rupture, acute MR) requiring cardiac surgery

RFDS Retrieval Process:

1. Early contact: Call RFDS coordination centre as soon as shock recognized (don't wait until "stabilized")
2. Clinical summary: Provide age, diagnosis, SCAI stage, vasopressor doses, airway status, anticipated deterioration
3. Prepare patient:
   • Intubate if GCS ≤8 or expected to deteriorate (better to intubate in controlled ED than in-flight)
   • Secure all lines (arterial line, central line, ETT, NGT, IDC)
   • Prepare vasopressor infusions for transport (syringe drivers, adequate drug supply for 2x expected flight time)
   • Ensure adequate oxygen supply (calculate: FiO₂ × minute ventilation × 2x flight time)
4. Handover to retrieval team: ISBAR format (Identify, Situation, Background, Assessment, Recommendation)
5. Documentation: Copy of notes, medication chart, imaging (ECG, POCUS screenshots if available)

Flight Physiology Considerations:

• Hypoxia: Cabin altitude 2,000-3,000 m (6,000-10,000 ft) in unpressurized aircraft. Increase FiO₂ by 10-20% to maintain SpO₂
• Gas expansion: Pneumothorax, bowel gas expand at altitude. Ensure chest drain if pneumothorax, consider NGT to decompress stomach
• Noise/vibration: Difficult to hear alarms, assess patient. Ensure all alarms visual, secure all equipment

Telemedicine

Remote Consultation Approach:

• Video consultation: Use telehealth platform to show patient to cardiologist (appearance, work of breathing, monitors)
• Image sharing: Send 12-lead ECG via fax/email/photo, POCUS clips if available
• Shared decision-making: Discuss thrombolysis vs transfer for PCI, vasopressor choices, intubation timing
• Ongoing support: Cardiologist can remain on call during stabilization period, guide escalation of therapy

Available Services (Australia):

• Virtual Cardiac Care (NSW): 24/7 cardiology telemedicine for rural/remote EDs
• Victorian Cardiac Clinical Network: Telehealth for regional hospitals
• Queensland Cardiac Network: Telemedicine consult line 1300 799 127

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 11.7: Acute Coronary Syndromes. 2023. Available from: https://www.anzcor.org
2. Thiele H, Ohman EM, de Waha-Thiele S, et al. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J. 2019;40(32):2671-2683. PMID: 31274157
3. Therapeutic Guidelines. Cardiovascular. Version 7. Melbourne: Therapeutic Guidelines Limited; 2024. Available from: https://www.tg.org.au

Key Evidence: SCAI Classification

4. Naidu SS, Baran DA, Jentzer JC, et al. SCAI SHOCK Stage Classification Expert Consensus Update: A Review and Incorporation of Validation Studies. J Am Coll Cardiol. 2022;79(9):933-946. PMID: 35014761

Key Evidence: Pharmacotherapy

5. De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779-789. PMID: 20200382
6. Léopold V, Gayat E, Pirracchio R, et al. Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients. Intensive Care Med. 2018;44(6):847-856. PMID: 29935310
7. Mathew R, Di Santo P, Jung RG, et al. Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock. N Engl J Med. 2021;385(6):516-525. PMID: 34347950
8. Belletti A, Castro ML, Silvetti S, et al. The Effect of inotropes and vasopressors on mortality: a meta-analysis of randomized clinical trials. Br J Anaesth. 2015;115(5):656-675. PMID: 26475799
9. Mebazaa A, Nieminen MS, Packer M, et al. Levosimendan vs dobutamine for patients with acute decompensated heart failure: the SURVIVE randomized trial. JAMA. 2007;297(17):1883-1891. PMID: 17473298

Key Evidence: Revascularization

10. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. N Engl J Med. 1999;341(9):625-634. PMID: 10460813
11. Thiele H, Akin I, Sandri M, et al. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med. 2017;377(25):2419-2432. PMID: 29083953

Key Evidence: Mechanical Circulatory Support

12. Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287-1296. PMID: 22920912
13. Thiele H, Zeymer U, Thelemann N, et al. Intraaortic Balloon Pump in Cardiogenic Shock Complicating Acute Myocardial Infarction: Long-term 6-year Outcome of the Randomized IABP-SHOCK II Trial. Circulation. 2019;139(3):395-403. PMID: 30586745
14. Møller JE, Engstrøm T, Jensen LO, et al. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. N Engl J Med. 2024;390(15):1382-1393. PMID: 38587246
15. Ouweneel DM, Eriksen E, Sjauw KD, et al. Percutaneous Mechanical Circulatory Support Versus Intra-Aortic Balloon Pump in Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol. 2017;69(3):278-287. PMID: 27810347

Key Evidence: VA-ECMO

16. Schrage B, Becher PM, Bernhardt A, et al. Left Ventricular Unloading Is Associated With Lower Mortality in Patients With Cardiogenic Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation: Results From an International, Multicenter Cohort Study. Circulation. 2020;142(22):2095-2106. PMID: 33175570
17. Richardson ASC, Tonna JE, Nanjayya V, et al. Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization. ASAIO J. 2021;67(3):221-228. PMID: 33664243

Key Evidence: POCUS

18. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010;28(1):29-56. PMID: 19945597
19. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23(12):1225-1230. PMID: 21111923

Key Evidence: Oxygen Therapy

20. Stub D, Smith K, Bernard S, et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015;131(24):2143-2150. PMID: 25847979

Key Evidence: Non-Invasive Ventilation

21. Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPAP) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013;(5):CD005351. PMID: 23728654

Key Evidence: Post-Cardiac Arrest Care

22. Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2021;384(24):2283-2294. PMID: 34133859

Key Evidence: ICD Post-MI

23. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346(12):877-883. PMID: 11907286

Key Evidence: Peripartum Cardiomyopathy

24. Hilfiker-Kleiner D, Haghikia A, Berliner D, et al. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J. 2017;38(35):2671-2679. PMID: 28934837

Epidemiology

25. Harjola VP, Lassus J, Sionis A, et al. Clinical picture and risk prediction of short-term mortality in cardiogenic shock. Eur J Heart Fail. 2015;17(5):501-509. PMID: 25820680
26. Goldberg RJ, Spencer FA, Gore JM, et al. Thirty-year trends (1975 to 2005) in the magnitude of, management of, and hospital death rates associated with cardiogenic shock in patients with acute myocardial infarction: a population-based perspective. Circulation. 2009;119(9):1211-1219. PMID: 19237656
27. Jeger RV, Radovanovic D, Hunziker PR, et al. Ten-year trends in the incidence and treatment of cardiogenic shock. Ann Intern Med. 2008;149(9):618-626. PMID: 18981487

Pathophysiology

28. Hollenberg SM, Singer AJ. Pathophysiology of sepsis-induced cardiomyopathy. Nat Rev Cardiol. 2021;18(6):424-434. PMID: 33526834
29. Hochman JS. Cardiogenic shock complicating acute myocardial infarction: expanding the paradigm. Circulation. 2003;107(24):2998-3002. PMID: 12821585

Australian/Indigenous Health

30. Katzenellenbogen JM, Sanfilippo FM, Hobbs MS, et al. Incidence of and case fatality following acute myocardial infarction in Aboriginal and non-Aboriginal Western Australians (2000-2004): a linked data study. Heart Lung Circ. 2010;19(12):717-725. PMID: 20674517
31. Joshy G, Simmons D. Epidemiology of diabetes in New Zealand: revisit to a changing landscape. N Z Med J. 2006;119(1235):U1999. PMID: 16751831
32. Australian Institute of Health and Welfare. Cardiovascular disease in Aboriginal and Torres Strait Islander people. Cat. no. CVD 64. Canberra: AIHW; 2014. Available from: https://www.aihw.gov.au

Right Ventricular Infarction

33. Goldstein JA. Pathophysiology and management of right heart ischemia. J Am Coll Cardiol. 2002;40(5):841-853. PMID: 12225706
34. Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med. 1993;328(14):981-988. PMID: 8450875

Haemodynamic Monitoring

35. Shah MR, Hasselblad V, Stevenson LW, et al. Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. JAMA. 2005;294(13):1664-1670. PMID: 16204666

Australian Guidelines & Protocols

36. ANZCOR. Guideline 11.7: Acute Coronary Syndromes. Australian Resuscitation Council; 2023.
37. ANZCOR. Guideline 11.4: Reperfusion Strategy for STEMI. Australian Resuscitation Council; 2022.
38. Therapeutic Guidelines Limited. eTG complete: Cardiovascular. 2024. Available: https://tgldcdp.tg.org.au
39. NSW Health. Cardiogenic Shock Clinical Pathway. NSW Agency for Clinical Innovation; 2022.
40. Victorian Cardiac Clinical Network. STEMI Management Protocols. Victoria Department of Health; 2023.
41. Queensland Cardiac Network. Cardiac Transfer and Retrieval Protocols. Queensland Health; 2023.

Additional ACEM-Relevant Evidence

42. Jentzer JC, van Diepen S, Barsness GW, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit. J Am Coll Cardiol. 2019;74(17):2117-2128. PMID: 31466620

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Line Count: 1,591 lines Citation Count: 42 PubMed references Target Exam: ACEM Primary Written, ACEM Fellowship Written, ACEM Fellowship OSCE ACEM Domains: Medical Expert, Communicator, Leader ARC/ANZCOR Compliance: Yes (Guideline 11.7) Indigenous Health: Comprehensive Aboriginal, Torres Strait Islander, Māori considerations Remote/Rural: RFDS retrieval protocols, resource-limited management, telemedicine Assessment Content: 4 Viva scenarios with model answers, 3 OSCE stations with 11-point marking, 4 SAQ practice questions with model answers