Primary percutaneous coronary intervention (PPCI) is the accepted standard of therapy in acute myocardial infarction (AMI) [ 1 ]. Speed in its application is the foremost goal of most medical care systems. How complete the revascularization with PPCI should be in AMI patients with multivessel disease (MVD) is an ongoing debate. Both culprit-only and multivessel PCI strategies can be supported by current evidence, which is not extensive and less than perfect. Operators presently must use sound clinical judgment to develop a strategic approach in an individual patient. Approximately 10% of AMIs are complicated by cardiogenic shock (CS), with overall mortality exceeding 50%, compared with <10% mortality in hemodynamically stable AMI patients. The high mortality exists despite the use of left ventricular support devices like the intra-aortic balloon pump and the percutaneous Impella CP pump [ 2 3 4 ]. Results of randomized trials evaluating use of circulatory support devices have been disappointing. However, newly emerging data suggest that the timing of circulatory support is critically important, with evidence favoring early initiation [ 5 ]. The pathophysiology of CS in this situation is very complex, perhaps reflecting widespread activation of inflammatory mediator cascades leading to systemic vasodilation, generalized hypoperfusion, multiple end-organ damage, and circulatory collapse, in addition to the low cardiac output from the ischemic myocardial insult. A vicious downward spiral can ensue, which in AMI patients with MVD may be worsened by ongoing myocardial ischemia due to residual flow-limiting coronary lesions, further compounding this difficult problem [ 2 , 6 , 7 ].