Cardiogenic shock natural history, complications and prognosis: Difference between revisions

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{{Cardiogenic shock}}
{{Cardiogenic shock}}
{{CMG}}
{{CMG}}; {{AE}} {{AZ}} {{JS}} {{sali}}
 
==Overview==
==Overview==
'''Cardiogenic shock''' (CS) is a clinical condition, defined as a state of systemic [[hypoperfusion]] originated in [[heart failure|cardiac failure]], in the presence of adequate [[intravascular]] volume, typically followed by [[hypotension]], which leads to insufficient ability to meet [[oxygen]] and [[nutrient]] demands of [[organs]] and other peripheral tissues.<ref>{{Cite book  | last1 = Hasdai | first1 = David. | title = Cardiogenic shock : diagnosis and treatmen | date = 2002 | publisher = Humana Press | location = Totowa, N.J. | isbn = 1-58829-025-5 | pages =  }}</ref> It may range from mild to severe [[hypoperfusion]] and may be defined in terms of [[hemodynamic]] parameters, which according to most studies, means a state in which [[systolic blood pressure]] is persistently < 90 mm Hg or < 80 mm Hg, for longer than 1 hour, with adequate or elevated left and right [[ventricular]] filling pressures that does not respond to isolated fluid administration, is secondary to [[heart failure|cardiac failure]] and occurs with signs of [[hypoperfusion]] ([[oliguria]], [[cool extremities]], [[cyanosis]] and [[altered mental status]]) or a [[cardiac index]] of < 2.2 L/min/m² (on [[inotropic]], [[vasopressor]] or circulatory device support) or < 1.8-2.2 L/min/m² (off support) and pulmonary artery wedge pressure > 18 mm Hg.<ref>{{cite book | last = Hochman | first = Judith | title = Cardiogenic shock | publisher = Wiley-Blackwell | location = Chichester, West Sussex, UK Hoboken, NJ | year = 2009 | isbn = 1405179260  }}</ref><ref name="GoldbergGore1991">{{cite journal|last1=Goldberg|first1=Robert J.|last2=Gore|first2=Joel M.|last3=Alpert|first3=Joseph S.|last4=Osganian|first4=Voula|last5=de Groot|first5=Jacques|last6=Bade|first6=Jurgen|last7=Chen|first7=Zuoyao|last8=Frid|first8=David|last9=Dalen|first9=James E.|title=Cardiogenic Shock after Acute Myocardial Infarction|journal=New England Journal of Medicine|volume=325|issue=16|year=1991|pages=1117–1122|issn=0028-4793|doi=10.1056/NEJM199110173251601}}</ref><ref name="GoldbergSamad1999">{{cite journal|last1=Goldberg|first1=Robert J.|last2=Samad|first2=Navid A.|last3=Yarzebski|first3=Jorge|last4=Gurwitz|first4=Jerry|last5=Bigelow|first5=Carol|last6=Gore|first6=Joel M.|title=Temporal Trends in Cardiogenic Shock Complicating Acute Myocardial Infarction|journal=New England Journal of Medicine|volume=340|issue=15|year=1999|pages=1162–1168|issn=0028-4793|doi=10.1056/NEJM199904153401504}}</ref><ref>{{Cite journal  | last1 = Menon | first1 = V. | last2 = Slater | first2 = JN. | last3 = White | first3 = HD. | last4 = Sleeper | first4 = LA. | last5 = Cocke | first5 = T. | last6 = Hochman | first6 = JS. | title = Acute myocardial infarction complicated by systemic hypoperfusion without hypotension: report of the SHOCK trial registry. | journal = Am J Med | volume = 108 | issue = 5 | pages = 374-80 | month = Apr | year = 2000 | doi =  | PMID = 10759093 }}</ref><ref name="Hasdai-1999">{{Cite journal  | last1 = Hasdai | first1 = D. | last2 = Holmes | first2 = DR. | last3 = Califf | first3 = RM. | last4 = Thompson | first4 = TD. | last5 = Hochman | first5 = JS. | last6 = Pfisterer | first6 = M. | last7 = Topol | first7 = EJ. | title = Cardiogenic shock complicating acute myocardial infarction: predictors of death. GUSTO Investigators. Global Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries. | journal = Am Heart J | volume = 138 | issue = 1 Pt 1 | pages = 21-31 | month = Jul | year = 1999 | doi =  | PMID = 10385759 }}</ref><ref name="Fincke-2004">{{Cite journal  | last1 = Fincke | first1 = R. | last2 = Hochman | first2 = JS. | last3 = Lowe | first3 = AM. | last4 = Menon | first4 = V. | last5 = Slater | first5 = JN. | last6 = Webb | first6 = JG. | last7 = LeJemtel | first7 = TH. | last8 = Cotter | first8 = G. | title = Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry. | journal = J Am Coll Cardiol | volume = 44 | issue = 2 | pages = 340-8 | month = Jul | year = 2004 | doi = 10.1016/j.jacc.2004.03.060 | PMID = 15261929 }}</ref><ref name="DzavikCotter2007">{{cite journal|last1=Dzavik|first1=V.|last2=Cotter|first2=G.|last3=Reynolds|first3=H. R.|last4=Alexander|first4=J. H.|last5=Ramanathan|first5=K.|last6=Stebbins|first6=A. L.|last7=Hathaway|first7=D.|last8=Farkouh|first8=M. E.|last9=Ohman|first9=E. M.|last10=Baran|first10=D. A.|last11=Prondzinsky|first11=R.|last12=Panza|first12=J. A.|last13=Cantor|first13=W. J.|last14=Vered|first14=Z.|last15=Buller|first15=C. E.|last16=Kleiman|first16=N. S.|last17=Webb|first17=J. G.|last18=Holmes|first18=D. R.|last19=Parrillo|first19=J. E.|last20=Hazen|first20=S. L.|last21=Gross|first21=S. S.|last22=Harrington|first22=R. A.|last23=Hochman|first23=J. S.|title=Effect of nitric oxide synthase inhibition on haemodynamics and outcome of patients with persistent cardiogenic shock complicating acute myocardial infarction: a phase II dose-ranging study|journal=European Heart Journal|volume=28|issue=9|year=2007|pages=1109–1116|issn=0195-668X|doi=10.1093/eurheartj/ehm075}}</ref> Despite the many possible causes for the [[heart failure|cardiac failure]], the most common is [[left ventricular failure]] in the setting of [[myocardial infarction]].<ref name="HochmanBuller2000">{{cite journal|last1=Hochman|first1=Judith S|last2=Buller|first2=Christopher E|last3=Sleeper|first3=Lynn A|last4=Boland|first4=Jean|last5=Dzavik|first5=Vladimir|last6=Sanborn|first6=Timothy A|last7=Godfrey|first7=Emilie|last8=White|first8=Harvey D|last9=Lim|first9=John|last10=LeJemtel|first10=Thierry|title=Cardiogenic shock complicating acute myocardial infarction—etiologies, management and outcome: a report from the SHOCK Trial Registry|journal=Journal of the American College of Cardiology|volume=36|issue=3|year=2000|pages=1063–1070|issn=07351097|doi=10.1016/S0735-1097(00)00879-2}}</ref>
In the presence of CS, a pathological cycle develops in which [[ischemia]], the initial aggression, leads to [[myocardial]] dysfunction. This will affect parameters like the [[cardiac output]], [[stroke volume]] and [[myocardial]] [[perfusion]] thereby worsening the [[ischemia]]. The body will then initiate a series of compensatory mechanisms, such as [[sympathetic]] stimulation of the [[heart]] and activation of the [[RAAS|renin/angiotensin/aldosterone system]], trying to overcome the [[cardiac]] aggression, however, this will ultimately lead to a downward spiral worsening of the [[ischemia]]. [[Inflammatory]] mediators, originated in the [[MI|infarcted]] area, will also intervene at some point causing [[myocardial]] depression, decreasing [[contractility]] and worsening [[hypotension]]. [[Lactic acidosis]] will also develop, resulting from the poor [[tissue]] [[perfusion]], that is responsible for a shift in [[metabolism]] to [[glycolysis]], which will further depress the [[myocardium]], thereby worsening the clinical scenario.<ref>{{Cite book  | last1 = Hasdai | first1 = David. | title = Cardiogenic shock : diagnosis and treatmen | date = 2002 | publisher = Humana Press | location = Totowa, N.J. | isbn = 1-58829-025-5 | pages =  }}</ref><ref name="pmid10391815">{{cite journal| author=Hollenberg SM, Kavinsky CJ, Parrillo JE| title=Cardiogenic shock. | journal=Ann Intern Med | year= 1999 | volume= 131 | issue= 1 | pages= 47-59 | pmid=10391815 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10391815  }} </ref>
CS has several [[risk factors]] which will contribute to the progression of the condition. Depending on these underlying factors and in concordance to the pathological mechanism responsible for the development of CS, the patient will have higher or lower probability of developing [[complications]], of which the most common are [[cardiac]], [[renal]] and [[pulmonary]]. The presence of certain [[risk factors]] and the [[etiology]] behind the [[shock]] will dictate the [[outcome]] of the condition. Despite the decreasing [[incidence]] and [[mortality rate]] seen throughout recent years, CS is still associated with a poor [[prognosis]], particularly in [[elderly]] patients.
==Natural History==
*As the name implies, cardiogenic shock (CS) consists of a [[shock]] of [[cardiac]] origin, with adequate [[intravascular]] volume (therefore ruling out [[hypovolemic]] cause), with [[hypoperfusion]] of [[myocardium]] and peripheral tissues.
*There are different possible causes for this condition, of which the [[left ventricular]] [[myocardial infarction]] is the most common.
*There is also the possibility of mechanical [[complications]], arising from the [[myocardial infarction]], leading to the [[pump failure]] that is underneath CS, such as [[mitral regurgitation]] and [[ventricular septal defect]].<ref>{{Cite book  | last1 = Hasdai | first1 = David. | title = Cardiogenic shock : diagnosis and treatmen | date = 2002 | publisher = Humana Press | location = Totowa, N.J. | isbn = 1-58829-025-5 | pages =  }}</ref> The common basic mechanism underneath CS is the [[ischemia]]. Because of it, the [[myocardium]] fails to contract properly, thereby affecting [[cardiac output]].
*This abnormality worsens the initial [[ischemia]], which then deteriorates even further the [[ventricular function]], creating the so called ''"downward spiral"''.<ref name="pmid10391815">{{cite journal| author=Hollenberg SM, Kavinsky CJ, Parrillo JE| title=Cardiogenic shock. | journal=Ann Intern Med | year= 1999 | volume= 131 | issue= 1 | pages= 47-59 | pmid=10391815 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10391815  }} </ref>
*When [[ischemia]] reaches a point that the [[left ventricular]] [[myocardium]] fails to pump properly, parameters like [[stroke volume]] and [[cardiac output]] will therefore decrease.
*The [[pressure]] gradient produced between the [[pressure]] within the [[coronary arteries]] and the [[left ventricle]], along with the duration of the [[diastole]], dictate [[myocardial]] [[perfusion]].
*This will be compromised by the [[hypotension]] and the [[tachycardia]], worsening the [[myocardial]] [[ischemia]] and the [[perfusion]] of other vital organs.
*The fact that the [[heart]] is the only organ that benefits from a low [[blood pressure]], as [[afterload]] decreases, makes these [[hemodynamic|hemodynamical]] changes both beneficial and detrimental. The [[pump failure]] will then decrease the ability to push the [[blood]] out of the [[ventricle]], thereby increasing the [[ventricular]] [[diastolic pressure|diastolic pressures]].
*This will not only reduce the [[coronary]] [[perfusion pressure]], as it will also increase the [[ventricle]] wall stress, so that the [[myocardial]] [[oxygen]] requirements will also raise, consequently propagating the [[ischemia]].<ref name="pmid10391815">{{cite journal| author=Hollenberg SM, Kavinsky CJ, Parrillo JE| title=Cardiogenic shock. | journal=Ann Intern Med | year= 1999 | volume= 131 | issue= 1 | pages= 47-59 | pmid=10391815 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10391815  }} </ref><ref name="ReynoldsHochman2008">{{cite journal|last1=Reynolds|first1=H. R.|last2=Hochman|first2=J. S.|title=Cardiogenic Shock: Current Concepts and Improving Outcomes|journal=Circulation|volume=117|issue=5|year=2008|pages=686–697|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.613596}}</ref><ref>{{Cite book  | last1 = Hasdai | first1 = David. | title = Cardiogenic shock : diagnosis and treatmen | date = 2002 | publisher = Humana Press | location = Totowa, N.J. | isbn = 1-58829-025-5 | pages =  }}</ref>
*The [[hypoperfusion]] of the peripheral tissues leads to the release of [[catecholamines]], such as [[norepinephrine]], which will increase the [[heart]]'s [[contractility]] and peripheral [[blood flow]], by causing constriction of [[arterioles]], together with [[angiotensin II]], to maintain [[perfusion]].
*This mechanism will also increase the [[heart]]'s [[oxygen]] demand and have proarrhythmic and [[cardiotoxic|myocardiotoxic]] consequences.
*The increased [[SVR]] coupled with the low [[cardiac output]] will lead to an even more pronounced reduction of tissue perfusion.<ref name="ReynoldsHochman2008">{{cite journal|last1=Reynolds|first1=H. R.|last2=Hochman|first2=J. S.|title=Cardiogenic Shock: Current Concepts and Improving Outcomes|journal=Circulation|volume=117|issue=5|year=2008|pages=686–697|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.613596}}</ref>
*The [[ischemia]] generated by all these processes increases the [[diastolic]] stiffness of the [[ventricle]] wall and this, along with the [[left ventricular dysfunction]], will increase the [[left atrial]] pressure.
*The increased [[left atrial]] pressure will propagate through the [[pulmonary veins]], generating [[pulmonary congestion]], which by decreasing [[oxygen]] exchanges, leads to [[hypoxia]].
*The [[hypoxia]] will further worsen the [[ischemia]] of the [[myocardium]] and the [[pulmonary congestion]] will propagate its effect through the [[pulmonary arteries]] to the [[right ventricle]], hence jeopardizing its performance.
*Once [[myocardial]] function is affected, the body will put in motion compensatory mechanisms to try to increase the [[cardiac output]].
*These include:<ref>{{Cite book  | last1 = Hasdai | first1 = David. | title = Cardiogenic shock : diagnosis and treatmen | date = 2002 | publisher = Humana Press | location = Totowa, N.J. | isbn = 1-58829-025-5 | pages =  }}</ref>
**[[Tachycardia]] and increased [[contractility]] through [[sympathetic]] stimulation
**Activation of the [[RAAS|renin/angiotensin/aldosterone system]], leading to fluid retention and consequently increased [[preload]]
*However, these compensatory mechanisms eventually become maladaptive seeing that:<ref name="ReynoldsHochman2008">{{cite journal|last1=Reynolds|first1=H. R.|last2=Hochman|first2=J. S.|title=Cardiogenic Shock: Current Concepts and Improving Outcomes|journal=Circulation|volume=117|issue=5|year=2008|pages=686–697|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.613596}}</ref><ref>{{Cite book  | last1 = Hasdai | first1 = David. | title = Cardiogenic shock : diagnosis and treatmen | date = 2002 | publisher = Humana Press | location = Totowa, N.J. | isbn = 1-58829-025-5 | pages =  }}</ref>
*[[Tachycardia]] and increased [[contractility]] will increase [[myocardium|cardiac muscle]] [[oxygen]] demand, thereby exacerbating the initial [[ischemia]];
*[[Vasoconstriction]], as a response to impaired [[cardiac output]], in order to try to maintain [[coronary artery]] [[perfusion]] and systemic [[blood pressure]] ([[SVR]]) increases [[myocardial]] [[afterload]], leading to an impairment in [[myocardial]] performance and an increase in its [[oxygen]] demand, worsening [[ischemia]];
*The activation of the neurohormonal cascade will promote retention of [[water retention|water]] and [[sodium]], in order to compensate for the [[hypotension]] and improve [[perfusion]], yet this will also exacerbate [[pulmonary edema]].
*The prolonged systemic [[hypoperfusion]] and [[hypoxia]] will cause a shift in [[cellular metabolism]], prioritizing [[glycolysis]], leading to a state of [[lactic acidosis]], which jeopardizes [[contractility]] and [[systolic]] performance, thereby affecting the previously described system.
*On the case of [[right ventricular infarction]], the underlying mechanism of disease is similar to the one described for [[left ventricular]] [[infarction]], with the particularity that it usually evolves to affect [[left ventricular function]] as well.
*All these factors affecting [[oxygen]] demand and [[cardiac]] performance create a vicious cycle that if not interrupted, may eventually lead to death.<ref>{{Cite book  | last1 = Hasdai | first1 = David. | title = Cardiogenic shock : diagnosis and treatmen | date = 2002 | publisher = Humana Press | location = Totowa, N.J. | isbn = 1-58829-025-5 | pages =  }}</ref>
==Complications==
[[Complications]] of cardiogenic shock include:
===Cardiac===
*A downward spiral of [[hypotension]] leading to reduced [[coronary]] [[perfusion]] leading to [[hypotension]] and further reduction in [[coronary]] and peripheral tissue [[perfusion]]
*[[Heart block]]<ref name="pmid6326559">{{cite journal| author=Braat SH, de Zwaan C, Brugada P, Coenegracht JM, Wellens HJ| title=Right ventricular involvement with acute inferior wall myocardial infarction identifies high risk of developing atrioventricular nodal conduction disturbances. | journal=Am Heart J | year= 1984 | volume= 107 | issue= 6 | pages= 1183-7 | pmid=6326559 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6326559  }} </ref>
*[[Ventricular septal rupture]]<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref>
*Ventricular [[free wall rupture]]<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref>
*[[Valvular]] abnormalities<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref>
===Neurologic===
*[[Brain damage]]
*[[Coma]]
===Renal===
*[[Renal failure]] - [[Oliguria]]
===Pulmonary===
*Cardiogenic [[pulmonary edema]]


==Natural History, Complications and Prognosis==
==Prognosis==
===Complications===
*The prognosis of cardiogenic shock (CS) will be dictated by several factors, including: the underlying condition precipitating the progression into [[shock]], the [[risk factors]] owned by the patient; the severity of the [[hemodynamic]] disorder; along with the possible emergence of [[complications]] during the process of the disease.
Complications of cardiogenic shock include:
*To better help in the prediction of the evolution of the cardiogenic shock along with the prognosis of the patient, some important facts are relevant to underline:
====Cardiac====
*CS occurs in 8% of hospitalized [[STEMI]] patients, with a [[mortality rate]] of 50-60% within 30 days.<ref>{{Cite journal  | last1 = Antman | first1 = EM. | last2 = Hand | first2 = M. | last3 = Armstrong | first3 = PW. | last4 = Bates | first4 = ER. | last5 = Green | first5 = LA. | last6 = Halasyamani | first6 = LK. | last7 = Hochman | first7 = JS. | last8 = Krumholz | first8 = HM. | last9 = Lamas | first9 = GA. | title = 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal = J Am Coll Cardiol | volume = 51 | issue = 2 | pages = 210-47 | month = Jan | year = 2008 | doi = 10.1016/j.jacc.2007.10.001| PMID = 18191746 }}</ref>
A downward spiral of hypotension leading to reduced coronary perfusion leading to further hypotension and a further reduction in coronary perfusion
*CS carries a very poor [[prognosis]], particularly in the [[elderly]]. In the GUSTO 1 trial, the following were identified as correlates of higher [[mortality]] among patients with CS:<ref>Hasdai D, Califf RM, Thompson TD, et al. Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction. J Am Coll Cardiol. Jan 2000;35(1):136-43.</ref>
====Neurologic====
**Older age
Coma
**Prior [[MI]]
====Renal====
**[[Signs]] of [[hypoperfusion]] including cold and [[clammy skin]]
Oligurin [[renal failure]]
**[[Altered mental state]]
====Pulmonary====
**[[Oliguria]]
Cardiogenic [[pulmonary edema]]
*CS is associated with more severe lesions of the [[coronary]] territories, with 53% of patients in the ''SHOCK trial'' suffering from disease in three coronary arteries and 16% with predominant [[left main coronary artery]] disease.<ref name="Wong-2000">{{Cite journal  | last1 = Wong | first1 = SC. | last2 = Sanborn | first2 = T. | last3 = Sleeper | first3 = LA. | last4 = Webb |first4 = JG. | last5 = Pilchik | first5 = R. | last6 = Hart | first6 = D. | last7 = Mejnartowicz | first7 = S. | last8 = Antonelli | first8 = TA. |last9 = Lange | first9 = R. | title = Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? | journal = J Am Coll Cardiol | volume = 36 | issue = 3 Suppl A | pages = 1077-83 | month = Sep | year = 2000 | doi = | PMID = 10985708 }}</ref>
* The [[mortality rate]] in CS is significantly higher when the culprit lesion is located in the [[left main coronary artery]] or [[saphenous vein]] [[graft]], compared to those with lesions located in the [[circumflex]], [[left anterior descending]], or [[right coronary artery]].<ref name="Sanborn-2003">{{Cite journal  | last1 = Sanborn | first1 = TA. | last2 = Sleeper | first2 = LA. | last3 = Webb | first3 = JG. | last4 = French | first4 = JK. | last5 = Bergman | first5 = G. | last6 = Parikh | first6 = M. | last7 = Wong | first7 = SC. | last8 = Boland | first8 = J. | last9 = Pfisterer | first9 = M. | title = Correlates of one-year survival inpatients with cardiogenic shock complicating acute myocardial infarction: angiographic findings from the SHOCK trial. | journal = J Am Coll Cardiol | volume = 42 | issue = 8 | pages = 1373-9 | month = Oct | year = 2003 | doi =  | PMID = 14563577 }}</ref>
*Among the causes of CS following [[MI]], [[ventricular septal rupture]] has one of the highest [[mortality rate]]s post-[[MI]], around 87.3%<ref name="pmid10985713">{{cite journal| author=Menon V, Webb JG, Hillis LD, Sleeper LA, Abboud R, Dzavik V et al.| title=Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK? | journal=J Am Coll Cardiol | year= 2000 | volume= 36 | issue= 3 Suppl A | pages= 1110-6 | pmid=10985713 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10985713  }} </ref>
*The [[prognosis]] is in part dictated by the amount of [[myocardium]] affected and the ability to reperfuse the [[ischemic]] [[myocardium]]. The sooner the [[ischemia]] is treated, better chances of a good [[outcome]] there will be<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref>
* There is no difference between the [[mortality rate]] of CS complicating [[STEMI]] or CS complicating [[NSTEMI]].<ref name="Holmes-1999">{{Cite journal  | last1 = Holmes | first1 = DR. | last2 = Berger | first2 = PB. | last3 = Hochman | first3 = JS. | last4 = Granger | first4 = CB. | last5 = Thompson | first5 = TD. | last6 = Califf | first6 = RM. | last7 = Vahanian | first7 = A. | last8 = Bates | first8 = ER. | last9 = Topol | first9 = EJ. | title = Cardiogenic shock in patients with acute ischemic syndromes with and without ST-segment elevation. | journal = Circulation | volume = 100 | issue = 20 | pages = 2067-73 | month = Nov | year = 1999 | doi = | PMID = 10562262 }}</ref>
* The [[left ventricular ejection fraction]] ([[LVEF]]) and the severity of [[mitral regurgitation]] ([[MR]]) are good [[echocardiographic]] predictors for the [[mortality rate]] of CS.<ref name="Picard-2003">{{Cite journal  | last1 = Picard | first1 = MH. | last2 = Davidoff | first2 = R. | last3 = Sleeper | first3 = LA. | last4 = Mendes | first4 = LA. | last5 = Thompson | first5 = CR. | last6 = Dzavik | first6 = V. | last7 = Steingart | first7 = R. | last8 = Gin | first8 = K. | last9 = White | first9 = HD. | title = Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock. | journal = Circulation | volume = 107 | issue = 2 | pages = 279-84 | month = Jan | year = 2003 | doi = | PMID = 12538428 }}</ref>
*The only way to prevent CS and to improve the outcome, is by early [[reperfusion]] therapy of [[MI]]. Early [[revascularization]] therapy, particularly by [[PCI]], has shown global improvement in [[echocardiographic]] indicators, such as the [[LVEF]] and [[MR]] grade and therefore in the [[outcome]] and [[prognosis]] of these patients.<ref name="Picard-2003">{{Cite journal  | last1 = Picard | first1 = MH. | last2 = Davidoff | first2 = R. | last3 = Sleeper | first3 = LA. | last4 = Mendes | first4 = LA. | last5 = Thompson | first5 = CR. | last6 = Dzavik | first6 = V. | last7 = Steingart | first7 = R. | last8 = Gin | first8 = K. | last9 = White | first9 = HD. | title = Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock. | journal = Circulation | volume = 107 | issue = 2 | pages = 279-84 | month = Jan | year = 2003 | doi =  | PMID = 12538428 }}</ref>


===Prognosis===
Cardiogenic shock carries a very poor prognosis, particularly in the elderly. In the GUSTO 1 trial, the following were identified as correlates of higher mortality among patients with cardiogenic shock:<ref>Hasdai D, Califf RM, Thompson TD, et al. Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction. J Am Coll Cardiol. Jan 2000;35(1):136-43.</ref>
*Older age
*Prior MI
*Signs of hypoperfusion including cold, clammy skin
*[[Altered mental state]]
*[[Oliguria]]
==References==
==References==
{{reflist|2}}
{{Reflist|2}}
 
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Latest revision as of 21:23, 23 December 2019

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Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Cardiogenic shock from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

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MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, M.D. [2] João André Alves Silva, M.D. [3] Syed Musadiq Ali M.B.B.S.[4]

Overview

Cardiogenic shock (CS) is a clinical condition, defined as a state of systemic hypoperfusion originated in cardiac failure, in the presence of adequate intravascular volume, typically followed by hypotension, which leads to insufficient ability to meet oxygen and nutrient demands of organs and other peripheral tissues.[1] It may range from mild to severe hypoperfusion and may be defined in terms of hemodynamic parameters, which according to most studies, means a state in which systolic blood pressure is persistently < 90 mm Hg or < 80 mm Hg, for longer than 1 hour, with adequate or elevated left and right ventricular filling pressures that does not respond to isolated fluid administration, is secondary to cardiac failure and occurs with signs of hypoperfusion (oliguria, cool extremities, cyanosis and altered mental status) or a cardiac index of < 2.2 L/min/m² (on inotropic, vasopressor or circulatory device support) or < 1.8-2.2 L/min/m² (off support) and pulmonary artery wedge pressure > 18 mm Hg.[2][3][4][5][6][7][8] Despite the many possible causes for the cardiac failure, the most common is left ventricular failure in the setting of myocardial infarction.[9] In the presence of CS, a pathological cycle develops in which ischemia, the initial aggression, leads to myocardial dysfunction. This will affect parameters like the cardiac output, stroke volume and myocardial perfusion thereby worsening the ischemia. The body will then initiate a series of compensatory mechanisms, such as sympathetic stimulation of the heart and activation of the renin/angiotensin/aldosterone system, trying to overcome the cardiac aggression, however, this will ultimately lead to a downward spiral worsening of the ischemia. Inflammatory mediators, originated in the infarcted area, will also intervene at some point causing myocardial depression, decreasing contractility and worsening hypotension. Lactic acidosis will also develop, resulting from the poor tissue perfusion, that is responsible for a shift in metabolism to glycolysis, which will further depress the myocardium, thereby worsening the clinical scenario.[10][11] CS has several risk factors which will contribute to the progression of the condition. Depending on these underlying factors and in concordance to the pathological mechanism responsible for the development of CS, the patient will have higher or lower probability of developing complications, of which the most common are cardiac, renal and pulmonary. The presence of certain risk factors and the etiology behind the shock will dictate the outcome of the condition. Despite the decreasing incidence and mortality rate seen throughout recent years, CS is still associated with a poor prognosis, particularly in elderly patients.

Natural History

Complications

Complications of cardiogenic shock include:

Cardiac

Neurologic

Renal

Pulmonary

Prognosis

References

  1. ↑ Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  2. ↑ Hochman, Judith (2009). Cardiogenic shock. Chichester, West Sussex, UK Hoboken, NJ: Wiley-Blackwell. ISBN 1405179260.
  3. ↑ Goldberg, Robert J.; Gore, Joel M.; Alpert, Joseph S.; Osganian, Voula; de Groot, Jacques; Bade, Jurgen; Chen, Zuoyao; Frid, David; Dalen, James E. (1991). "Cardiogenic Shock after Acute Myocardial Infarction". New England Journal of Medicine. 325 (16): 1117–1122. doi:10.1056/NEJM199110173251601. ISSN 0028-4793.
  4. ↑ Goldberg, Robert J.; Samad, Navid A.; Yarzebski, Jorge; Gurwitz, Jerry; Bigelow, Carol; Gore, Joel M. (1999). "Temporal Trends in Cardiogenic Shock Complicating Acute Myocardial Infarction". New England Journal of Medicine. 340 (15): 1162–1168. doi:10.1056/NEJM199904153401504. ISSN 0028-4793.
  5. ↑ Menon, V.; Slater, JN.; White, HD.; Sleeper, LA.; Cocke, T.; Hochman, JS. (2000). "Acute myocardial infarction complicated by systemic hypoperfusion without hypotension: report of the SHOCK trial registry". Am J Med. 108 (5): 374–80. PMID 10759093. Unknown parameter |month= ignored (help)
  6. ↑ Hasdai, D.; Holmes, DR.; Califf, RM.; Thompson, TD.; Hochman, JS.; Pfisterer, M.; Topol, EJ. (1999). "Cardiogenic shock complicating acute myocardial infarction: predictors of death. GUSTO Investigators. Global Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries". Am Heart J. 138 (1 Pt 1): 21–31. PMID 10385759. Unknown parameter |month= ignored (help)
  7. ↑ Fincke, R.; Hochman, JS.; Lowe, AM.; Menon, V.; Slater, JN.; Webb, JG.; LeJemtel, TH.; Cotter, G. (2004). "Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry". J Am Coll Cardiol. 44 (2): 340–8. doi:10.1016/j.jacc.2004.03.060. PMID 15261929. Unknown parameter |month= ignored (help)
  8. ↑ Dzavik, V.; Cotter, G.; Reynolds, H. R.; Alexander, J. H.; Ramanathan, K.; Stebbins, A. L.; Hathaway, D.; Farkouh, M. E.; Ohman, E. M.; Baran, D. A.; Prondzinsky, R.; Panza, J. A.; Cantor, W. J.; Vered, Z.; Buller, C. E.; Kleiman, N. S.; Webb, J. G.; Holmes, D. R.; Parrillo, J. E.; Hazen, S. L.; Gross, S. S.; Harrington, R. A.; Hochman, J. S. (2007). "Effect of nitric oxide synthase inhibition on haemodynamics and outcome of patients with persistent cardiogenic shock complicating acute myocardial infarction: a phase II dose-ranging study". European Heart Journal. 28 (9): 1109–1116. doi:10.1093/eurheartj/ehm075. ISSN 0195-668X.
  9. ↑ Hochman, Judith S; Buller, Christopher E; Sleeper, Lynn A; Boland, Jean; Dzavik, Vladimir; Sanborn, Timothy A; Godfrey, Emilie; White, Harvey D; Lim, John; LeJemtel, Thierry (2000). "Cardiogenic shock complicating acute myocardial infarction—etiologies, management and outcome: a report from the SHOCK Trial Registry". Journal of the American College of Cardiology. 36 (3): 1063–1070. doi:10.1016/S0735-1097(00)00879-2. ISSN 0735-1097.
  10. ↑ Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  11. ↑ 11.0 11.1 11.2 Hollenberg SM, Kavinsky CJ, Parrillo JE (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815.
  12. ↑ Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  13. ↑ 13.0 13.1 13.2 Reynolds, H. R.; Hochman, J. S. (2008). "Cardiogenic Shock: Current Concepts and Improving Outcomes". Circulation. 117 (5): 686–697. doi:10.1161/CIRCULATIONAHA.106.613596. ISSN 0009-7322.
  14. ↑ Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  15. ↑ Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  16. ↑ Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  17. ↑ Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  18. ↑ Braat SH, de Zwaan C, Brugada P, Coenegracht JM, Wellens HJ (1984). "Right ventricular involvement with acute inferior wall myocardial infarction identifies high risk of developing atrioventricular nodal conduction disturbances". Am Heart J. 107 (6): 1183–7. PMID 6326559.
  19. ↑ 19.0 19.1 19.2 19.3 Ng, R.; Yeghiazarians, Y. (2011). "Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies". Journal of Intensive Care Medicine. 28 (3): 151–165. doi:10.1177/0885066611411407. ISSN 0885-0666.
  20. ↑ Antman, EM.; Hand, M.; Armstrong, PW.; Bates, ER.; Green, LA.; Halasyamani, LK.; Hochman, JS.; Krumholz, HM.; Lamas, GA. (2008). "2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 51 (2): 210–47. doi:10.1016/j.jacc.2007.10.001. PMID 18191746. Unknown parameter |month= ignored (help)
  21. ↑ Hasdai D, Califf RM, Thompson TD, et al. Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction. J Am Coll Cardiol. Jan 2000;35(1):136-43.
  22. ↑ Wong, SC.; Sanborn, T.; Sleeper, LA.; Webb, JG.; Pilchik, R.; Hart, D.; Mejnartowicz, S.; Antonelli, TA.; Lange, R. (2000). "Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?". J Am Coll Cardiol. 36 (3 Suppl A): 1077–83. PMID 10985708. Unknown parameter |month= ignored (help)
  23. ↑ Sanborn, TA.; Sleeper, LA.; Webb, JG.; French, JK.; Bergman, G.; Parikh, M.; Wong, SC.; Boland, J.; Pfisterer, M. (2003). "Correlates of one-year survival inpatients with cardiogenic shock complicating acute myocardial infarction: angiographic findings from the SHOCK trial". J Am Coll Cardiol. 42 (8): 1373–9. PMID 14563577. Unknown parameter |month= ignored (help)
  24. ↑ Menon V, Webb JG, Hillis LD, Sleeper LA, Abboud R, Dzavik V; et al. (2000). "Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?". J Am Coll Cardiol. 36 (3 Suppl A): 1110–6. PMID 10985713.
  25. ↑ Holmes, DR.; Berger, PB.; Hochman, JS.; Granger, CB.; Thompson, TD.; Califf, RM.; Vahanian, A.; Bates, ER.; Topol, EJ. (1999). "Cardiogenic shock in patients with acute ischemic syndromes with and without ST-segment elevation". Circulation. 100 (20): 2067–73. PMID 10562262. Unknown parameter |month= ignored (help)
  26. ↑ 26.0 26.1 Picard, MH.; Davidoff, R.; Sleeper, LA.; Mendes, LA.; Thompson, CR.; Dzavik, V.; Steingart, R.; Gin, K.; White, HD. (2003). "Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock". Circulation. 107 (2): 279–84. PMID 12538428. Unknown parameter |month= ignored (help)


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