Left Ventricular Support for the Management of Cardiogenic Shock Sooner May Be Better

There have been few randomized trials in the setting of cardiogenic shock over the last several decades (1), yet the management of this condition has shifted substantially since the first largescale randomized trial that established the use of reperfusion as key to improving survival (2). The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial demonstrated improved survival whether reperfusi on therapy was performed within the first 6 h of onset of acute myocardial infarction (AMI) in cardiogenic shock (AMICS) or later (2). This finding was at odds with the then-current wisdom that early reperfusion improves mortality in noncardiogenic shock myocardial infarction (3). Thus, the urgency to apply any treatment strategy in AMICS was muted by a lack of clear evidence for "earlier is better." This, coupled with the challenges of performing randomized clinical trials in the setting of cardiogenic shock, let alone a complex strategy trial to test whether early application of reperfusion therapy or mechanical support devices would affect outcomes, has hampered progress.