Cardiogenic shock: 'Going to the mat' - Is it needed and does it work?

Cardiogenic shock remains a highly lethal event. Fortunately, recent data indicate that some of these high risk patients derive particular survival benefit from aggressive treatment strategies. As yet, there are no randomized trial data, although two trials are currently being performed. Selection bias can affect results, as pointed out by Hockman et al., who found that selection for angiography was associated with improved outcome irrespective of whether revascularization was performed. That not withstanding, in aggregate, the expanding data set indicates that the outcome of cardiogenic shock can be improved with measures to raise blood pressure (therapy improving coronary perfusion), restore persistent flow to the infarct territory (PTCA, stents, or coronary bypass graft surgery) or support the circulation more optimally. The wider spread use of stents may be particularly important. Preliminary data indicate that stenting improves outcome compared to conventional PTCA using the endpoints of TIMI 3 flow, reocclusion, and mortality. Accordingly, stents and other aggressive therapy may be particularly important. These measures will not result in immortality for all patients with cardiogenic shock but do show that the high mortality can be significantly reduced in carefully selected patients. Intense efforts are underway to identify those patients at risk for developing shock or those patients who could benefit from 'going to the mat' with expensive resources to optimize outcome.