ACS with cardiogenic shock: challenging clinical settings in need of trans-disciplinary management

Coronary artery disease Course resource

20 March 2026

This iHF Course 2026 session addresses the complex management of patients presenting with acute coronary syndrome (ACS) complicated by cardiogenic shock due to ventricular septal defect (VSD). In this case-based discussion, the multidisciplinary panel, discuss the overall management of VSD-related cardiogenic shock: SCAI classification, hemodynamic phenotyping, MCS and surgery.

Management of inferior Stemi with post-infarction muscular VSD – A case-based discussion

The session relies on a detailed clinical case of a middle-aged male with late-presentation inferior STEMI, who developed a post-infarction muscular VSD. The patient was initially managed with urgent PCI, followed by identification of VSD via echocardiography.

How to assess cardiogenic shock severity?

The panel elaborated on the challenges of assessing cardiogenic shock severity using hemodynamic classifications such as the SCAI (Society for Cardiovascular Angiography and Interventions) stages, emphasizing that patients may appear hemodynamically stable but are at risk of rapid deterioration. Echocardiography and invasive measurements such as Swan-Ganz catheters are vital for quantifying shunt severity (Qp/Qs ratio) and systemic output, which may be misleadingly high due to shunting.

Precision phenotyping and pharmacological choice

The panel emphasizes that effective management requires rapid hemodynamic phenotyping to select the appropriate pharmacological support:

Vasoconstricted Phenotype with septal defect ("Cold and Wet"): Hypotensive drugs should be used to decrease systemic vascular resistance, facilitate LV ejection into the aorta and improve effective systemic flow.
Vasoconstricted phenotype without septal defect (“Cold and dry”): Inodilators like dobutamine (5 µg/kg/min) are preferred to restore systemic perfusion.
Mixed shock Phenotype ("Warm and Wet"): Norepinephrine is the first-line inopressor to restore vascular tone.

How to manage ACS patient complicated by VSD-related cardiogenic shock?

Mechanical circulatory support & surgical strategies

The role and timing of mechanical circulatory support (MCS) devices were extensively reviewed, alongside the surgical possibilities, giving an overview of the different management options in case of cardiogenic shock with VSD. Among them, IABP remains recommended for early-stage shock (SCAI A/B) as a bridging tool, while ECMO and percutaneous microaxial pumps are indicated in more advanced shock (SCAI C and beyond) to maintain systemic perfusion and unload the left ventricle.
Surgical repair remains the standard treatment for VSD, preferably delayed at least 7 days to allow fibrotic tissue formation, with percutaneous closure reserved for high-risk inoperable patients.

Early diagnosis, trans-disciplinary decision-making and monitoring: the other pillars of cardiogenic shock management

The panel highlighted that management success heavily depends on early diagnosis, vigilant monitoring, timely referral to specialized shock centers with multidisciplinary teams, and use of shock algorithms and registries to standardize care. Post-surgical care includes guideline-directed medical therapy for heart failure and frequent patient monitoring.

Despite advances, available evidence is mainly observational, indicating the need for further randomized trials to optimize care strategies. This session underscores the importance of trans-disciplinary collaboration to improve survival and functional recovery in this challenging patient population.