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Answer 1
  1. Insert an intra-aortic balloon counterpulsation. Intra-aortic balloon counterpulsation is recommended for patients with MI when cardiogenic shock is not quickly reversed with pharmacologic therapy.1 It is also used as a stabilizing measure prior to angiography and prompt revascularization.1 The synchronous deflation and inflation of the balloon during the cardiac cycle reduces afterload during systole and augments blood flow in coronary circulation during diastole, respectively.2 In addition to their positive inotropic effect, phosphodiesterase inhibitors also have some vasodilatory properties and should not be used in patients with low mean arterial pressure. Nitroprusside also has a vasodilatory effect and should not be used in low cardiac output states. Aggressive fluid resuscitation may be limited by acute pulmonary edema from left ventricular dysfunction in patients with cardiogenic shock. Digoxin can be used in shock to control heart rate but only if atrial arrhythmias exist.

     Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST- elevation myocardial infarction-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) [published erratum appears in Circulation 2005;111:2013]. Circulation 2004;110:588-636.

    2. Scheidt S, Wilner G, Mueller H, et al. Intra-aortic balloon counterpulsation in cardiogenic shock. Report of a cooperative clinical trial. N Engl J Med 1973;288:979-84.

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