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. Fibrinolytic therapy is reserved for patients without contraindications within 24 hours of MI for whom revascu- larization is considered not feasible for technical, anatomic, or patient-related issues. The need for hemodynamic support with inotropic therapy, IABP, or both should be assessed on an individual basis. Observational data on the usefulness of IABP in this setting are conflicting. A meta-analysis supports IABP therapy as an adjunct to fibrinolysis but not to primary PCI.458 Compared with IABP, LV assist devices may provide superior hemodynamic support and serve as more effective bridges to recovery or transplantation, though experience with their use in this setting is limited.463,464 Medical support with inotropes and vasopressor agents should be individualized and guided by invasive hemodynamic monitoring. Use of dopamine in this setting may be associated with excess hazard.465 9.2. Severe HF The development of HF after STEMI is an indication for angiography with intent to proceed with revascularization if not previously performed. LV myocardium may be ischemic, stunned, hibernating, or irrevocably injured, and viability assessment may be needed depending on the timing of revas- cularization. Ischemic (functional) mitral regurgitation due to LV remodeling may coexist, progress over time, and require surgical attention depending on its severity. Medical treatment is based on the use of diuretics, vasodilators, and inotropic agents when required. Inhibitors of the renin-angiotensin- aldosterone system should be provided as tolerated, and the indications for beta-blocker therapy should be evaluated con- tinuously throughout the hospital course. 9.3. 