**18. Management of patients with cardiogenic shock**

Cardiogenic shock may develop in up to 3% of NSTE-ACS patients during hospitalization and has become the most frequent cause of in-hospital mortality in this setting [197–199]. One or more partial or complete vessel occlusions may result in severe heart failure, especially in cases of pre-existing LV dysfunction, reduced cardiac output and ineffective peripheral organ perfusion. More than two-thirds of patients have three-vessel CAD. Cardiogenic shock may also be related to mechanical complications of NSTEMI, including mitral regurgitation related to papillary muscle dysfunction or rupture and ventricular septal or free wall rupture. In patients with cardiogenic shock, immediate coronary angiography is indicated and PCI is the most frequently used revascularization modality. If the coronary anatomy is not suitable for PCI, patients should undergo emergent CABG. The value of intra-aortic balloon counter pulsation in MI complicated by cardiogenic shock has been challenged [200]. Extracorporeal membrane oxygenation and/or implantable LV assist devices may be considered in selected patients.
