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cardiogenic shock

Failure to maintain adequate perfusion of vital organs secondary to impaired myocardial function. Classification: 1) hemodynamic stability with high risk, 46% (mortality 3%)* [7] 2) hypotension/tachycardia, 30% 3) hypoperfusion, 16% 4) deterioration, 7% 5) refractory shock, 1% (mortality 67%)* [7] * cancer worsens mortality at every stage [7] Etiology: 1) myocardial infarction 2) hemodynamically significant arrhythmias a) tachyarrhythmias 1] ventricular tachycardia 2] supraventricular tachycardia b) bradyarrhythmias 3) cardiomyopathy 4) acute valvular regurgitation (papillary muscle rupture) 5) acute ventricular septal defect (post MI) 6) severe valvular stenosis a) aortic stenosis b) mitral stenosis c) subaortic stenosis 7) acute coronary vasospasm a) Prinzmetal's angina b) cocaine 8) rupture of free ventricular wall 9) congenital heart disease with increased cardiac workload Pathology: 1) elevated intracardiac pressure a) high cardiac filling pressures b) pulmonary artery wedge pressure > 18 torr 2) depressed cardiac output - cardiac index < 2.0 liters/min/m2 3) increased systemic vascular resistance 4) 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: 1) echocardiography 2) cardiac catheterization Complications: - median early mortality 41% [10] - patient risk factors: - >= 75 years. malignancy, peripheral arterial disease, chronic kidney disease, valvular heart disease, female - presentation risk factors: - cardiac arrest, left main coronary artery disease, LVEF < 30%, hemodialysis, need for mechanical circulatory support - procedural risk factors: - thrombolysis in myocardial infarction after percutaneous coronary intervention, delayed revascularization, hemodialysis, mechanical ventilation [10] - factors associated with lower mortality - coronary artery bypass graft, percutaneous coronary intervention [10] Management: 1) initial goal is to maintain a) systemic blood pressure b) cardiac output c) myocardial perfusion 2) volume expansion 3) identify & treat precipitating factors 4) 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] - mortality (40% in hospital mortality) is high regardless of inotrope 5) right heart catheterization does not improve outcomes in hospitalized patients with heart failure [3] 6) intra-aortic balloon counterpulsation for patients that do not respond to inotropic agents [3] 7) PCI vs CAPG (early) [see SHOCK trial]

Related

dobutamine (Dobutrex) Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial

Specific

cold shock

General

heart disease (cardiac disease) shock

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 135-36
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 211-214
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17, 19. American College of Physicians, Philadelphia 2006, 2012, 2015, 2022
  4. 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: 20200382 - Levy JH. Treating shock - Old drugs, new ideas. N Engl J Med 2010 Mar 4; 362:841. PMID: 20200389
  5. Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation. 2008 Feb 5;117(5):686-97 PMID: 18250279
  6. 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: 24686400
  7. 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: 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: 31548098 https://www.sciencedirect.com/science/article/pii/S0735109719374492
  8. 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: 34347952 https://www.nejm.org/doi/10.1056/NEJMoa2026845
  9. 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: 28817482 - Yager P, Noviski N. Shock. Pediatr Rev 2010 Aug; 31:311. PMID: 20679096 - Mendelson J. Emergency department management of pediatric shock. Emerg Med Clin North Am 2018 May; 36:427. PMID: 29622332 - Bronicki RA et al. Critical heart failure and shock. Pediatr Crit Care Med 2016 Aug; 17:S124
  10. Jung RG, Stotts C, Gupta A et al. Prognostic factors associated with mortality in cardiogenic shock - A systematic review and meta-analysis. NEJM Evid. 2024 Nov;3(11):EVIDoa2300323 PMID: 39437131 https://evidence.nejm.org/doi/10.1056/EVIDoa2300323