Acute severe LV failure (most common cause of cardiogenic shock)

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Often from massive anterior infarct

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ST elevation often seen

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Consider in aggressive titration of HF meds → decompensation

Mechanical complications of AMI

Papillary muscle rupture or dysfunction w/ severe MR

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Classically 2-7 days post-MI

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More common with inferior/posterior infarct because of single blood supply to posterior papillary muscle via the RCA

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Often with an early systolic murmur vs. classic holosystolic murmur because of early systolic equalization of LV → LA pressure

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Echo with severe MR, +/− flail leaflet

Acute ventricular septal defect (vsd)

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Higher risk with “wrap around LAD” should be alerted to this complication when anterior STEMI presents with concomitant inferior lead ST elevation (OR 17)⁸

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Anterior MI → apical VSD

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Inferior MI → basal VSD

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Holosystolic murmur radiating to R sternal border often with a thrill

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PO₂ step-up from RA to RV/PA (use the swan that’s in!)

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Echo dx by color Doppler

cardiac tamponade (free wall rupture or hemorrhagic effusion)

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Beck’s triad: hypotension, distant heart sounds, JVD

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Pulsus paradoxus

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Echo support of dx by effusion + RA/RV diastolic collapse, PW Doppler

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Swan: Equalization of diastolic pressures – RA = RVD = PAD Can see as an early complication of PCI (coronary rupture)

RV infarct

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Seen most often with concomitant inferior wall MI

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Check R sided leads

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JVD, + Kussmaul’s sign, hypotensive response to NTG and diuretics, responds to fluids, generally clear lungs

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May see bradycardia, heart block, GI symptoms from RCA ACS

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Echo will show RV dilation, hypokinesis

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Swan: RA pressure >10 mm Hg and RA:PCWP >0.8

Stress cardiomyopathy (Tako tsubo) Or “broken heart syndrome”

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Consider as a cause of cardiogenic shock in ST elevation with normal epicardial coronary arteries

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Preponderance of post menopausal females, often significant “life stressor” is identifiable

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Look for apical or more rarely basal ballooning

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Consider acute LVOT obstruction as an etiology of shock; if present, trial of phenylephrine

RV failure secondary to massive PE

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Signs and symptoms of acute RV failure in the absence of AMI

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Echo with dilated RV

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Diagnosis by Helical CT angiography

Proximal aortic dissection

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Pulse deficits and focal neuro exam

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Suspect with widened mediastinum on CXR

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Severe AI with extension to the root on Echo

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Cardiac tamponade

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May see inferior STEMI because the RCA is most often compromised by dissection

Tachyarrhythmias

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AF/Atrial flutter w/ RVR, VT

Bradyarrhythmias

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Anterior infarct → Mobitz II or CHB with slow ventricular escape

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Inferior infarct → sinus bradycardia, Mobitz I → CHB usually with junctional escape

Myocarditis

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Acute LV dysfunction, positive enzymes, +/− fever and viral prodrome

Endocarditis

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Acute valvular regurgitation in the setting of septic picture and vegetations

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Positive blood cultures

Hemorrhagic shock

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Either as a primary presentation or as a complication of thrombolytics and anticoagulants

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Shock with low filling pressures

Septic shock

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Can see LV dysfunction in severe sepsis

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Can see positive cardiac enzymes

LV, left ventricular; LAD, left anterior descending; LVOT, left ventricular outfloor tract.