The onset of cardiogenic shock due to mechanical compli- cations after STEMI is bimodal; most cases occur within 24 hours. For those with pump failure, 15% of cases occur at time of presentation, and 85% develop during hospitalization. Revascularization with timely PCI or CABG is the preferred reperfusion strategy for patients with STEMI and shock due to pump failure, irrespective of the time delay. Shock or severe HF is perhaps the only clinical scenario in which acute revascularization of significant stenoses in noninfarct arter- ies can be justified. In the SHOCK trial, mortality rates at 6 and 1 year were significantly lower in patients allocated to emergency revascularization than in patients who received immediate medical stabilization.212,354 Nearly two thirds of the patients in the medical stabilization group received fibrinolytic therapy, and 25% underwent delayed revasculariza- tion. IABP support was used in 86% of both groups. Although the trial did not show benefit with emergency revascularization for the prespecified age group >75 years, the small number of patients in the trial did not allow for firm conclusions to be drawn about management. Elderly patients offered emer- gency revascularization in the nonrandomized SHOCK regis- try had a substantial adjusted survival benefit with emergency revascularization compared with delayed or no revasculariza- Similar findings in favor of early revascularization for selected elderly patients were reported from 2 additional Although age alone is not a contraindication to emergency revascularization in this setting, individual judg- ment based on comorbidities, functional status, and patient directives is necessary in the elderly. Triage and immediate transfer to a PCI-capable facility with on-site cardiac surgi- cal backup are indicated for patients with STEMI complicated by shock. 