Cardiogenic shock echocardiography or ultrasound: Difference between revisions

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{{Cardiogenic shock}}
{{Cardiogenic shock}}
{{CMG}}; {{AE}} {{JS}}
{{CMG}}; {{AE}} {{JS}} {{sali}}


==Overview==
==Overview==
Attending to the catastrophic [[outcome]] of cardiogenic shock in a very short time span, its [[diagnosis]] must be reached as early as possible in order for proper [[therapy]] to be started. This period until [[diagnosis]] and [[therapy|treatment]] initiation is particularly important in the case of cardiogenic shock since the [[mortality rate]] of this condition complicating acute-[[MI]] is very high, along with the fact that the ability to revert the damage caused, through [[reperfusion]] techniques, declines considerably with [[diagnostic]] delays. Therefore and due to the unstable state of these patients, the [[diagnostic]] evaluations are usually performed as supportive measures are initiated. The [[diagnostic]] measures should start with the proper [[medical history|history]] and [[physical examination]], including [[blood pressure]] measurement, followed by an [[EKG]], [[echocardiography]], [[chest x-ray]] and collection of [[blood]] samples for evaluation. The physician should keep in mind the common features of [[shock]], irrespective of the type of [[shock]], in order to avoid delays in the [[diagnosis]]. Although not all [[shock]] patients present in the same way, these features include: abnormal [[mental status]], [[cool extremities]], [[clammy skin]], manifestations of [[hypoperfusion]], such as [[hypotension]] and [[oliguria]], as well as evidence of [[metabolic acidosis]] on the [[blood]] results. [[Echocardiography]] is an important imaging modality for the evaluation of the patient with cardiogenic shock. This test will allow the identification of certain characteristics that, when complemented by a proper [[medical history]] and [[physical examination]], will likely prompt to the [[diagnosis]]. These may include: poor wall motion, [[papillary muscle rupture]], [[pseudoaneurysm]]s, [[ventricular septal defects]], among others. The [[echocardiographic]] findings may also suggest or rule out a different [[diagnosis]]. The test will provide information about the overall [[hemodynamic]] status of the [[heart]] as well, which may reveal to be vital in order to plan further measures and predict the [[outcome]].<ref>{{Cite book  | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages =  }}</ref>
[[Echocardiography]] is an important [[imaging]] modality for the evaluation of the patient with [[cardiogenic shock]]. This test will allow the identification of certain characteristics that, when complemented by a proper [[medical history]] and [[physical examination]], will likely prompt to the [[diagnosis]]. These may include: poor wall motion, [[papillary muscle rupture]], [[pseudoaneurysm]]s, [[ventricular septal defects]], among others. The [[echocardiographic]] findings may also suggest or rule out a different [[diagnosis]]. The test will provide information about the overall [[hemodynamic]] status of the [[heart]] as well, which may reveal to be vital in order to plan further measures and predict the outcome. [[Transthoracic]] and [[transesophageal]] (in the case of inadequate visibility) [[echocardiography]] is increasingly used for non-invasive [[hemodynamic]] assessment and monitoring in the [[ICU]] setting. Using [[echocardiography]], it is possible to assess [[preload]], fluid responsiveness, [[systolic]] and [[diastolic]] [[cardiac function]], and calculate [[cardiac output]], [[intravascular]] and [[intra-cardiac pressures]]. It is the golden standard in the initial [[hemodynamic]] assessment and should be used as complementary tool in invasively monitored patients in the case of new circulatory or [[respiratory failure]]. [[Echocardiography]] is indispensable in the management of shock patients and is extremely powerful diagnostic role for the cardiac abnormalities ([[pericardial effusion]] and [[tamponade]], acute [[cor pulmonale]] and acute or [[chronic valvular disorders]]) as a cause for [[hemodynamic instability]]. It is the most important and suitable method for assessment of [[right ventricular function]], for diagnosis of [[septic]] [[cardiomyopathy]] and cardiac causes of weaning failure.


==Echocardiography==
==Echocardiography==
In recent years [[noninvasive]] means of estimating [[cardiac]] function have seen their usage increased considerably. These methods, such as [[echocardiography]], have helped reducing the use of [[invasive]] means, like [[right heart catheterization]], in [[acute coronary syndrome]] patients. [[Echocardiography]] with [[Doppler]] imaging has become common practice in recent years across many institutions, for bedside evaluation of [[cardiac]] status, including: [[PA]] [[systolic]] pressure, [[PCWP]], overall function, [[heart valve|valvular]] competence and eventual mechanical [[complications]] arising from [[ACS]], such as [[papillary muscle rupture]] or [[ventricular septal rupture]], helping in the confirmation of the [[diagnosis]]. The collection of [[hemodynamic]] parameters through [[echocardiography]] also contributes to a timely management of these patients, when compared to other more [[invasive]] methods. However, some possible drawbacks may arise in the interpretation of [[echocardiographic]] data, such as: overestimation of [[cardiac output]] in patients whose reason for cardiogenic shock is [[VSD]], as well as overestimation of [[PCWP]] in those with [[right ventricular myocardial infarction]] causing a leftward shift of the [[interventricular septum]]. Therefore, despite the importance of [[diagnostic imaging]] methods in assessing [[hemodynamic]] data and laboratory values, possibly confirming a suspected [[diagnosis]], these must always follow a careful assessment of the patient by a physician.<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="pmid16155391">{{cite journal| author=Porter A, Iakobishvili Z, Haim M, Behar S, Boyko V, Battler A et al.| title=Balloon-floating right heart catheter monitoring for acute coronary syndromes complicated by heart failure--discordance between guidelines and reality. | journal=Cardiology | year= 2005 | volume= 104 | issue= 4 | pages= 186-90 | pmid=16155391 | doi=10.1159/000088107 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16155391  }} </ref>
*In recent years [[noninvasive]] means of estimating [[cardiac]] function have seen their usage increased considerably.  
*These methods, such as [[echocardiography]], have helped reducing the use of [[invasive]] means, like [[right heart catheterization]], in [[acute coronary syndrome]] patients.  
*[[Echocardiography]] with [[Doppler]] imaging has become common practice in recent years across many institutions, for bedside evaluation of [[cardiac]] status, including: [[PA]] [[systolic]] pressure, [[PCWP]], overall function, [[heart valve|valvular]] competence and eventual mechanical [[complications]] arising from [[ACS]], such as [[papillary muscle rupture]] or [[ventricular septal rupture]], helping in the confirmation of the [[diagnosis]].  
*The collection of [[hemodynamic]] parameters through [[echocardiography]] also contributes to a timely management of these patients, when compared to other more [[invasive]] methods.  
*However, some possible drawbacks may arise in the interpretation of [[echocardiographic]] data, such as: overestimation of [[cardiac output]] in patients whose reason for cardiogenic shock is [[VSD]], as well as overestimation of [[PCWP]] in those with [[right ventricular myocardial infarction]] causing a leftward shift of the [[interventricular septum]].  
*Therefore, despite the importance of [[diagnostic imaging]] methods in assessing [[hemodynamic]] data and laboratory values, possibly confirming a suspected [[diagnosis]], these must always follow a careful assessment of the patient by a physician.<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="pmid16155391">{{cite journal| author=Porter A, Iakobishvili Z, Haim M, Behar S, Boyko V, Battler A et al.| title=Balloon-floating right heart catheter monitoring for acute coronary syndromes complicated by heart failure--discordance between guidelines and reality. | journal=Cardiology | year= 2005 | volume= 104 | issue= 4 | pages= 186-90 | pmid=16155391 | doi=10.1159/000088107 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16155391  }} </ref>


[[Echocardiography]] may be performed by 2 different approaches, the [[Transthoracic echocardiography|transthoracic]] and the [[Transesophageal echocardiography (TEE)|transesophageal]] approaches:
[[Echocardiography]] may be performed by 2 different approaches, the [[Transthoracic echocardiography|transthoracic]] and the [[Transesophageal echocardiography (TEE)|transesophageal]] approaches:
*'''[[Transthoracic echocardiography|Transthoracic]]''' - easily accessible, however, sometimes it does not provide an adequate image, particularly in critically ill patients on [[Mechanical ventilation|mechanical ventilatory support]]. It may underestimate certain conditions as well, such as a [[mitral regurgitation]] that may appear milder on this approach, later revealing more sever on the [[TEE]].
:*'''[[Transthoracic echocardiography|Transthoracic]]''' - easily accessible, however, sometimes it does not provide an adequate image, particularly in critically ill patients on [[Mechanical ventilation|mechanical ventilatory support]] or with [[chronic obstructive pulmonary disease]]. It may underestimate certain conditions as well, such as a [[mitral regurgitation]] that may appear milder on this approach, later revealing to be more sever on the [[TEE]].
*'''[[TEE|Tansesophageal]]''' - although not as accessible as the [[Transthoracic echocardiography|transthoracic]] approach, this allows for a better and more accurate visualization of the possible cause of cardiogenic shock, such as [[MR]] or [[VSR]], particularly when complemented by color flow [[Doppler]].
:*'''[[TEE|Tansesophageal]]''' - although not as accessible as the [[Transthoracic echocardiography|transthoracic]] approach, this allows for a better and more accurate visualization of the possible cause of cardiogenic shock, such as [[MR]] or [[VSR]], particularly when complemented by color flow [[Doppler]].


In a patient with cardiogenic shock complicating [[left ventricular failure|left]] or [[right ventricular dysfunction]], [[echocardiography]] may provide valuable findings to support the [[diagnosis]], including:<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="pmid18250279">{{cite journal| author=Reynolds HR, Hochman JS| title=Cardiogenic shock: current concepts and improving outcomes. | journal=Circulation | year= 2008 | volume= 117 | issue= 5 | pages= 686-97 | pmid=18250279 | doi=10.1161/CIRCULATIONAHA.106.613596 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18250279  }} </ref><ref name="Antman2004">{{cite journal|last1=Antman|first1=E. M.|title=ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)|journal=Circulation|volume=110|issue=5|year=2004|pages=588–636|issn=0009-7322|doi=10.1161/01.CIR.0000134791.68010.FA}}</ref>
*In a patient with cardiogenic shock complicating '''[[left ventricular failure|left]] or [[right ventricular dysfunction]]''', [[echocardiography]] may provide valuable findings to support the [[diagnosis]], including:<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="pmid18250279">{{cite journal| author=Reynolds HR, Hochman JS| title=Cardiogenic shock: current concepts and improving outcomes. | journal=Circulation | year= 2008 | volume= 117 | issue= 5 | pages= 686-97 | pmid=18250279 | doi=10.1161/CIRCULATIONAHA.106.613596 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18250279  }} </ref><ref name="Antman2004">{{cite journal|last1=Antman|first1=E. M.|title=ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)|journal=Circulation|volume=110|issue=5|year=2004|pages=588–636|issn=0009-7322|doi=10.1161/01.CIR.0000134791.68010.FA}}</ref>
*depressed [[left ventricle|left]] or [[right ventricle]] [[systolic]] function
:*depressed [[left ventricle|left]] or [[right ventricle]] [[systolic]] function
*elevated filling pressures
:*elevated filling pressures
*decreased [[stroke volume]]
:*decreased [[stroke volume]]
*[[tamponade]] from increased [[pericardial fluid]]
:*[[tamponade]] from increased [[pericardial fluid]]
*[[mitral regurgitation]]
:*[[mitral regurgitation]]
*proximal [[aortic dissection]]
:*proximal [[aortic dissection]]
*[[ventricular septal rupture]]
:*[[ventricular septal rupture]]


In the case of [[right ventricle myocardial infarction]], [[echocardiographic]] findings may include:<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><ref name="pmid6823853">{{cite journal| author=Lopez-Sendon J, Garcia-Fernandez MA, Coma-Canella I, Yangüela MM, Bañuelos F| title=Segmental right ventricular function after acute myocardial infarction: two-dimensional echocardiographic study in 63 patients. | journal=Am J Cardiol | year= 1983 | volume= 51 | issue= 3 | pages= 390-6 | pmid=6823853 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6823853  }} </ref><ref name="pmid6092446">{{cite journal| author=Dell'Italia LJ, Starling MR, Crawford MH, Boros BL, Chaudhuri TK, O'Rourke RA| title=Right ventricular infarction: identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques. | journal=J Am Coll Cardiol | year= 1984 | volume= 4 | issue= 5 | pages= 931-9 | pmid=6092446 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6092446  }} </ref>
*In the case of '''[[right ventricle myocardial infarction]]''', [[echocardiographic]] findings may include:<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><ref name="pmid6823853">{{cite journal| author=Lopez-Sendon J, Garcia-Fernandez MA, Coma-Canella I, Yangüela MM, Bañuelos F| title=Segmental right ventricular function after acute myocardial infarction: two-dimensional echocardiographic study in 63 patients. | journal=Am J Cardiol | year= 1983 | volume= 51 | issue= 3 | pages= 390-6 | pmid=6823853 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6823853  }} </ref><ref name="pmid6092446">{{cite journal| author=Dell'Italia LJ, Starling MR, Crawford MH, Boros BL, Chaudhuri TK, O'Rourke RA| title=Right ventricular infarction: identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques. | journal=J Am Coll Cardiol | year= 1984 | volume= 4 | issue= 5 | pages= 931-9 | pmid=6092446 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6092446  }} </ref>
*[[RV]] hypokinesis
:*[[RV]] hypokinesis
*[[RV]] akinesis
:*[[RV]] akinesis
*[[Right atrial enlargement]]
:*[[Right atrial enlargement]]
*[[Ventricular dilation]]
:*[[Ventricular dilation]]
*Bowing of [[intraventricular septum]] into the [[LV]]
:*Bowing of [[intraventricular septum]] into the [[LV]]


In acute [[mitral regurgitation]], [[echocardiographic]] findings may include:
*In '''acute [[mitral regurgitation]]''', the [[echocardiogram]] may be useful in:<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><ref name="pmid19564568">{{cite journal| author=Stout KK, Verrier ED| title=Acute valvular regurgitation. | journal=Circulation | year= 2009 | volume= 119 | issue= 25 | pages= 3232-41 | pmid=19564568 | doi=10.1161/CIRCULATIONAHA.108.782292 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19564568  }} </ref>
:*visualizing of the defect, thereby distinguishing it from [[VSR]], whose clinical findings may be similar
:*normal [[LV]] cavity concomitant with severe [[mitral regurgitation]], suggesting an acute event
:*visualization of the flail leaflet, along with the direction and size of the regurgitant jet
:*in case of suspicion of [[papillary muscle rupture]], not seen in [[transthoracic echocardiography]], [[TEE]] may be necessary


In [[ventricular septal rupture]], [[echocardiographic]] findings may include:
*In '''[[ventricular septal rupture]]''', [[echocardiographic]] findings may include:<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><ref name="pmid2329247">{{cite journal| author=Smyllie JH, Sutherland GR, Geuskens R, Dawkins K, Conway N, Roelandt JR| title=Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction. | journal=J Am Coll Cardiol | year= 1990 | volume= 15 | issue= 6 | pages= 1449-55 | pmid=2329247 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2329247  }} </ref>
:*the presence and location of the [[VSR]]
:*size of the [[shunt]]


In [[free wall rupture]], [[echocardiographic]] findings may include:
*In '''[[free wall rupture]] and [[tamponade]]''', [[echocardiographic]] findings may include:<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>
:*visualization of [[pericardial effusion]]
:*signs of [[cardiac tamponade]], such as:
::*>25% of respiratory variation in [[mitral]] inflow
::*[[diastolic]] collapse of [[RV]]
:*evaluation of the [[ventricular]] wall defect


Once the cause for the caidiogenic shock and instability of the patient have been resolved, [[echocardiography]] constitutes a good method to monitor the [[hemodynamic]] status of the [[heart]] during patient's [[recovery]] and follow-up.
Once the cause for the cardiogenic shock and instability of the patient have been resolved, [[echocardiography]] constitutes a good method to monitor the [[hemodynamic]] status of the [[heart]] during patient's [[recovery]] and follow-up.


==References==
==References==

Latest revision as of 18:24, 8 January 2020

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

Overview

Echocardiography is an important imaging modality for the evaluation of the patient with cardiogenic shock. This test will allow the identification of certain characteristics that, when complemented by a proper medical history and physical examination, will likely prompt to the diagnosis. These may include: poor wall motion, papillary muscle rupture, pseudoaneurysms, ventricular septal defects, among others. The echocardiographic findings may also suggest or rule out a different diagnosis. The test will provide information about the overall hemodynamic status of the heart as well, which may reveal to be vital in order to plan further measures and predict the outcome. Transthoracic and transesophageal (in the case of inadequate visibility) echocardiography is increasingly used for non-invasive hemodynamic assessment and monitoring in the ICU setting. Using echocardiography, it is possible to assess preload, fluid responsiveness, systolic and diastolic cardiac function, and calculate cardiac output, intravascular and intra-cardiac pressures. It is the golden standard in the initial hemodynamic assessment and should be used as complementary tool in invasively monitored patients in the case of new circulatory or respiratory failure. Echocardiography is indispensable in the management of shock patients and is extremely powerful diagnostic role for the cardiac abnormalities (pericardial effusion and tamponade, acute cor pulmonale and acute or chronic valvular disorders) as a cause for hemodynamic instability. It is the most important and suitable method for assessment of right ventricular function, for diagnosis of septic cardiomyopathy and cardiac causes of weaning failure.

Echocardiography

Echocardiography may be performed by 2 different approaches, the transthoracic and the transesophageal approaches:

  • the presence and location of the VSR
  • size of the shunt

Once the cause for the cardiogenic shock and instability of the patient have been resolved, echocardiography constitutes a good method to monitor the hemodynamic status of the heart during patient's recovery and follow-up.

References

  1. Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  2. Porter A, Iakobishvili Z, Haim M, Behar S, Boyko V, Battler A; et al. (2005). "Balloon-floating right heart catheter monitoring for acute coronary syndromes complicated by heart failure--discordance between guidelines and reality". Cardiology. 104 (4): 186–90. doi:10.1159/000088107. PMID 16155391.
  3. Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  4. Reynolds HR, Hochman JS (2008). "Cardiogenic shock: current concepts and improving outcomes". Circulation. 117 (5): 686–97. doi:10.1161/CIRCULATIONAHA.106.613596. PMID 18250279.
  5. Antman, E. M. (2004). "ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)". Circulation. 110 (5): 588–636. doi:10.1161/01.CIR.0000134791.68010.FA. ISSN 0009-7322.
  6. 6.0 6.1 6.2 6.3 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.
  7. Lopez-Sendon J, Garcia-Fernandez MA, Coma-Canella I, Yangüela MM, Bañuelos F (1983). "Segmental right ventricular function after acute myocardial infarction: two-dimensional echocardiographic study in 63 patients". Am J Cardiol. 51 (3): 390–6. PMID 6823853.
  8. Dell'Italia LJ, Starling MR, Crawford MH, Boros BL, Chaudhuri TK, O'Rourke RA (1984). "Right ventricular infarction: identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques". J Am Coll Cardiol. 4 (5): 931–9. PMID 6092446.
  9. Stout KK, Verrier ED (2009). "Acute valvular regurgitation". Circulation. 119 (25): 3232–41. doi:10.1161/CIRCULATIONAHA.108.782292. PMID 19564568.
  10. Smyllie JH, Sutherland GR, Geuskens R, Dawkins K, Conway N, Roelandt JR (1990). "Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction". J Am Coll Cardiol. 15 (6): 1449–55. PMID 2329247.


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