cardiogenic shock
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Introduction
Failure to maintain adequate perfusion of vital organs secondary to impaired myocardial function.
Classification
- hemodynamic stability with high risk, 46% (mortality 3%)*[7]
- hypotension/tachycardia, 30%
- hypoperfusion, 16%
- deterioration, 7%
- refractory shock, 1% (mortality 67%)*[7]
* cancer worsens mortality at every stage[7]
Etiology
- myocardial infarction
- hemodynamically significant arrhythmias
- cardiomyopathy
- acute valvular regurgitation (papillary muscle rupture)
- acute ventricular septal defect (post MI)
- severe valvular stenosis
- acute coronary vasospasm
- rupture of free ventricular wall
- congenital heart disease with increased cardiac workload
Pathology
- elevated intracardiac pressure
- high cardiac filling pressures
- pulmonary artery wedge pressure > 18 torr
- depressed cardiac output
- cardiac index < 2.0 liters/min/m2
- increased systemic vascular resistance
- decreased mean arterial blood pressure - < 60 torr*
* a mean arterial pressure of 65 mm Hg is the theshold at which there is sufficient pressure for organ perfusion (most humans)[3]
Laboratory
Management
- initial goal is to maintain
- volume expansion
- identify & treat precipitating factors
- inotropic agents
- epinephrine, dopamine, dobutamine for cardiogenic shock
- epinephrine is 1st line therapy for cold shock with hypotension
- dobutamine: also causes peripheral vasodilation
- dopamine
- milrinone: avoid with renal insufficiency
- norepinephrine may be most prudent choice[4]
- avoid norepinephrine in cardiogenic shock & cold shock with hypotension[9]
- controversy over which agent 1st line[4]
- no significant difference with milrinone vs dobutamine[8]
- epinephrine, dopamine, dobutamine for cardiogenic shock
- right heart catheterization does not improve outcomes in hospitalized patients with heart failure[3]
- intra-aortic balloon counterpulsation for patients that do not respond to inotropic agents[3]
- PCI vs CAPG (early) [see SHOCK trial]
More general terms
More specific terms
Additional terms
- dobutamine (Dobutrex)
- Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 135-36
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 211-214
- ↑ 3.0 3.1 3.2 3.3 Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17, 19. American College of Physicians, Philadelphia 2006, 2012, 2015, 2022
- ↑ 4.0 4.1 4.2 De Backer D et al Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 2010 Mar 4; 362:779 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20200382
Levy JH. Treating shock - Old drugs, new ideas. N Engl J Med 2010 Mar 4; 362:841. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20200389 - ↑ Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation. 2008 Feb 5;117(5):686-97 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18250279
- ↑ Nativi-Nicolau J, Selzman CH, Fang JC, Stehlik J. Pharmacologic therapies for acute cardiogenic shock. Curr Opin Cardiol. 2014 May;29(3):250-7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24686400
- ↑ 7.0 7.1 7.2 7.3 Jentzer JC et al. Cardiogenic shock classification to predict mortality in the cardiac intensive care unit. J Am Coll Cardiol 2019 Oct 29; 74:2117. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31548097 https://www.sciencedirect.com/science/article/pii/S0735109719362916b
Burkhoff D et al. The SCAI cardiogenic shock staging system gets taken for a test drive. J Am Coll Cardiol 2019 Oct 29; 74:2129 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31548098 https://www.sciencedirect.com/science/article/pii/S0735109719374492 - ↑ 8.0 8.1 Mathew R, Di Santo P, Jung RG et al. Milrinone as compared with dobutamine in the treatment of cardiogenic shock. N Engl J Med 2021 Aug 5; 385:516. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34347952 https://www.nejm.org/doi/10.1056/NEJMoa2026845
- ↑ 9.0 9.1 NEJM knowledge+ Question of the Week https://knowledgeplus.nejm.org/question-of-week/5108/
Davis AL et al. American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med 2017 Jun; 45:1061. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28817482
Yager P, Noviski N. Shock. Pediatr Rev 2010 Aug; 31:311. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20679096
Mendelson J. Emergency department management of pediatric shock. Emerg Med Clin North Am 2018 May; 36:427. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29622332
Bronicki RA et al. Critical heart failure and shock. Pediatr Crit Care Med 2016 Aug; 17:S124