<International Circulation>:  The management of cardiogenic shock is complex， achieved through a multi-specialty approach and these days， involving highly sophisticated technology. Moreover， things become increasingly difficult when it occurs as a complication of STEMI， and when it occurs as a refractory cardiogenic shock. What are your recommendations for management in this situation?

    Dr Hochman: The first approach to a patient with cardiogenic shock are the ABCs: you must ensure they are oxygenating; that ventilation is adequate; you have to rapidly support the blood pressure as usually they are profoundly hypotensive and hypoperfusing. We now have data to show that probably the best vasopressor to initiate first is norepinephrine in as low a dose as possible. And when in the setting of acute MI， reperfusion therapy is clearly the only therapy that actually changes outcome. If you are at a centre that can do angioplasty or bypass surgery and can get the patient revascularized and blood flow restored to the infarct-related artery， then that is the preferred therapy. It is superior to fibrinolytic therapy in cardiogenic shock. If you are at a facility with no access to angioplasty or bypass surgery， then fibrinolytic therapy should be used. It does save lives in cardiogenic shock cases.