Cardiogenic shock surgery: Difference between revisions

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__NOTOC__
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{{Cardiogenic shock}}
{{Cardiogenic shock}}
{{CMG}}
{{CMG}}; {{AE}} {{JS}} {{sali}}
 
==Overview==
==Overview==
Cardiogenic shock is considered an [[emergency]] and irrespectively to the [[therapeutic]] approach, the target goal of any [[therapy]] is prompt [[revascularization]] of [[ischemic myocardium]]. This should be achieved in the shortest timespan possible. There are two major categories of treatment for cardiogenic shock, the ''medical/conservative approach'' and the ''interventional approach''. The ideal [[therapy|treatment]] combines both mechanisms, in which medical therapy, after restored filling pressures, allows [[hemodynamic|hemodynamical]] stabilization of the patient, until interventional methods, that contribute to the reversal of the process leading to the [[shock]] state, may performed. The interventional approach may include [[PCI]] or [[coronary artery bypass graft surgery]] ([[CABG]]) and in both techniques the goal is not only reperfusion of the occluded [[coronary artery]], but also prevention of [[coronary artery|vessel]] reoclusion. If there is no access to a [[cardiac catheterization]] facility, nor the possibility of transferring the patient to one within 90 minutes, then immediately [[thrombolytic therapy]] should be considered. Other important factors to increase the chances of a better [[outcome]] are: [[mechanical ventilation]], in order to improve [[tissue]] [[oxygenation]], and close monitoring of the [[therapeutic]] dosages, particularly of [[vasoactive]] drugs, since these have been associated with excess [[mortality]] due to [[toxicity]] effects. Also, it is recommended [[invasive]] [[hemodynamic]] monitoring, in order to monitor and guide the effects of the [[therapy]] as well as the overall status of the patient. The success of [[reperfusion]] is usually suggested by the relief of [[symptoms]], restoration of [[hemodynamic]] parameters and electrical stability, as well as the reduction of at least 50% in the [[ST-segment]] on the [[EKG]], in the case of a [[STEMI]].


==Surgery==
==Surgery==
===Urgent revascularizaiton===
===Urgent Revascularizaiton===
If the patient has an [[ST elevation myocardial infarction]], then [[primary angioplasty]] should be considered to restore flow to the culprit artery. Consideration should also be given to restoration of flow in the non-culprit territories in the setting of cardiogenic shock.   
If the patient has an [[ST elevation myocardial infarction]], then [[primary angioplasty]] should be considered to restore flow to the culprit artery. Consideration should also be given to restoration of flow in the non-culprit territories in the setting of cardiogenic shock.   


Administration of streptokinase therapy to patients with cardiogenic shock has not been associated with an improvement in survival.<ref name="pmid2868337">{{cite journal |author= |title=Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI) |journal=Lancet |volume=1 |issue=8478 |pages=397–402 |year=1986 |month=February |pmid=2868337 |doi= |url=}}</ref>  These studies, however, oare older and are limited by the infrequent use of [[adjunctive PCI]].  If a patient is not deemed a candidate for [[primary angioplasty]], then consideration should be given to fibrinolyitc administration.
Administration of streptokinase therapy to patients with cardiogenic shock has not been associated with an improvement in survival.<ref name="pmid2868337">{{cite journal |author= |title=Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI) |journal=Lancet |volume=1 |issue=8478 |pages=397–402 |year=1986 |month=February |pmid=2868337 |doi= |url=}}</ref>  These studies, however, are older and are limited by the infrequent use of [[adjunctive PCI]].  If a patient is not deemed a candidate for [[primary angioplasty]], then consideration should be given to fibrinolyitc administration.


===Volume management===
===Volume Management===
The goal of managing the patient with cardiogenic shock is to optimize the filling of the left ventricle so that the [[Starling relationship]] and mechanical performance and contractility of the heart is optimized.  In the setting of [[acute MI]], a [[pulmonary capillary wedge pressure]] of 18 to 20 mm Hg may optimize left ventricular filling.  Filling pressures higher than this may lead to LV dilation, and poorer left ventricular function.
The goal of managing the patient with cardiogenic shock is to optimize the filling of the left ventricle so that the [[starling relationship]] and mechanical performance and contractility of the heart is optimized.  In the setting of [[acute MI]], a [[pulmonary capillary wedge pressure]] of 18 to 20 mm Hg may optimize left ventricular filling.  Filling pressures higher than this may lead to LV dilation, and poorer left ventricular function.


===Pharmacologic hemodynamic support===
===Pharmacologic Hemodynamic Support===
If hypotension persists despite adequate left ventricular filling pressures, then the addition of vasconstrictors and/or inotropes is suggested.  Hemodynamic monitoring is essential to assure that a target [[mean arterial pressure]] ([[MAP]]) of 60 to 65 mmHg is acheived to maintain perfusion to vital organs (brain, kidney, heart).
If hypotension persists despite adequate left ventricular filling pressures, then the addition of vasconstrictors and/or inotropes is suggested.  Hemodynamic monitoring is essential to assure that a target [[mean arterial pressure]] ([[MAP]]) of 60 to 65 mmHg is acheived to maintain perfusion to vital organs (brain, kidney, heart).


====Selection of a vasopressor or an inotrope====
====Selection of a Vasopressor or an Inotrope====
=====Systolic blood pressure (SBP) > 80 mm Hg=====
=====Systolic Blood Pressure (SBP) > 80 mm Hg=====
[[Dobutamine]] may be preferable over [[dopamine]] at this blood pressure. Dopamine increase contractility and heart rate and thereby increases myocardial oxygen demand. [[Dobutamine]] reduces the [[systemic vascular resistance]] and may not increase oxygen demands as much as dopamine, and is preferable at this systolic blood pressure. [[Phosphodiesterase inhibitors]] ([[PDI]]s) such as [[milrinone]] and [[inamrinone]] (formerly known as [[amrinone]]) are not dependent upon the adrenoreceptor activity and patients may not develop tolerance, and they may be less likely to increase myocardial oxygen demands. However, the addition of a vasopressor is often required as these agents reduce [[preload]] and [[afterload]].  PDIs are more likely to be associated with [[tachyarrhythmias]] than [[dobutamine]].
[[Dobutamine]] may be preferable over [[dopamine]] at this blood pressure. Dopamine increase contractility and heart rate and thereby increases myocardial oxygen demand. [[Dobutamine]] reduces the [[systemic vascular resistance]] and may not increase oxygen demands as much as dopamine, and is preferable at this systolic blood pressure. [[Phosphodiesterase inhibitors]] ([[PDI]]s) such as [[milrinone]] and [[inamrinone]] (formerly known as [[amrinone]]) are not dependent upon the adrenoreceptor activity and patients may not develop tolerance, and they may be less likely to increase myocardial oxygen demands. However, the addition of a vasopressor is often required as these agents reduce [[preload]] and [[afterload]].  PDIs are more likely to be associated with [[tachyarrhythmias]] than [[dobutamine]].


=====Systolic blood pressure (SBP) < 80 mm Hg=====
=====Systolic Blood Pressure (SBP) < 80 mm Hg=====
At systolic blood pressures < 80 mm Hg dopamine should be initiated first.  The patient may not tolerate the vasodilating effects of dobutamine at this blood pressure. The initial dose of dopamine is 5 to 10 mcg/kg/min.
At systolic [[blood pressures]] < 80 mm Hg dopamine should be initiated first.  The patient may not tolerate the vasodilating effects of [[dobutamine]] at this blood pressure. The initial dose of [[dopamine]] is 5 to 10 mcg/kg/min.


If the dopamine at doses of 20 mcg/kg/min does not achieve a MAP of 60-65 mm Hg, then norepinephrine can be added at an initial dose of 0.5 mcg/kg/min which can then be titrated up to 3.3 mcg/kg/min. Norepinephrine is avoided as a first line agent because of its adverse impact upon renal perfusion.
If the [[dopamine]] at doses of 20 mcg/kg/min does not achieve a MAP of 60-65 mm Hg, then [[norepinephrine]] can be added at an initial dose of 0.5 mcg/kg/min which can then be titrated up to 3.3 mcg/kg/min. [[Norepinephrine]] is avoided as a first line agent because of its adverse impact upon renal perfusion.


If norepinephrine does not generate a MAP of 60 mm Hg, then epinephrine can be added. Epinephrine increases both the [[stroke volume]] and [[heart rate]], but is associated with [[lactic acidosis]]
If [[norepinephrine]] does not generate a MAP of 60 mm Hg, then epinephrine can be added. [[Epinephrine]] increases both the [[stroke volume]] and [[heart rate]], but is associated with [[lactic acidosis]]


===Mechanical support===
===Mechanical Support===
====Intra-aortic balloon placement====
====Intra-aortic Balloon Placement====
In the setting of acute MI, the placement of an [[intra-aortic balloon pump]] (which reduces [[afterload|workload]] for the heart, and improves perfusion of the [[coronary arteries]]) should be considered.   
In the setting of acute MI, the placement of an [[intra-aortic balloon pump]] (which reduces [[afterload|workload]] for the heart, and improves perfusion of the [[coronary arteries]]) should be considered.   


A recent meta-analysis of randomized trial data, however, challenges this common practice and class 1B recommendation.<ref name="pmid19168529">{{cite journal |author=Sjauw KD, Engström AE, Vis MM, van der Schaaf RJ, Baan J, Koch KT, de Winter RJ, Piek JJ, Tijssen JG, Henriques JP |title=A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines? |journal=European Heart Journal |volume=30 |issue=4 |pages=459–68 |year=2009 |month=February |pmid=19168529 |doi=10.1093/eurheartj/ehn602 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=19168529}}</ref>  In a meta-analysis of seven randomized trials enrolling 1009 patient, IABP placement in STEMI was not associated with an improvement in mortality or in left ventricular function but was associated with a higher rate of stroke and bleeding.  When data from non-randomized cohort studies were evaluated in a meta-analysis (n=10,529 STEMI patients with cardiogenic shock), IABP placement was associated with an 18% relative risk reduction in 30 day mortality among patients treated with a fibrinolytic agent. This particular analysis is confounded by the fact that those patients in whom an [[IABP]] was placed underwent [[adjunctive percutaneous intervention]] (PCI) more frequently. In this non-randomized cohort analysis, [[IABP]] placement in patients undergoing [[primary angioplasty]] was associated with a 6% relative increase in mortality (p<0.0008).  Thus, neither randomized nor observational data support IABP placement in the setting of [[primary PCI]] for cardiogenic shock, and careful consideration should be given to the risk of [[stroke]] and bleeding  prior to [[IABP]] placement in this population.
A recent meta-analysis of randomized trial data, however, challenges this common practice and class 1B recommendation.<ref name="pmid19168529">{{cite journal |author=Sjauw KD, Engström AE, Vis MM, van der Schaaf RJ, Baan J, Koch KT, de Winter RJ, Piek JJ, Tijssen JG, Henriques JP |title=A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines? |journal=European Heart Journal |volume=30 |issue=4 |pages=459–68 |year=2009 |month=February |pmid=19168529 |doi=10.1093/eurheartj/ehn602 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=19168529}}</ref>  In a meta-analysis of seven randomized trials enrolling 1009 patient, [[IABP]] placement in [[STEMI]] was not associated with an improvement in mortality or in [[left ventricular function]] but was associated with a higher rate of [[stroke]] and bleeding.  When data from non-randomized cohort studies were evaluated in a meta-analysis (n=10,529 [[STEMI]] patients with [[cardiogenic shock]]), [[IABP]] placement was associated with an 18% relative risk reduction in 30 day mortality among patients treated with a [[fibrinolytic]] agent. This particular analysis is confounded by the fact that those patients in whom an [[IABP]] was placed underwent [[adjunctive percutaneous intervention]] (PCI) more frequently. In this non-randomized cohort analysis, [[IABP]] placement in patients undergoing [[primary angioplasty]] was associated with a 6% relative increase in mortality (p<0.0008).  Thus, neither randomized nor observational data support IABP placement in the setting of [[primary PCI]] for cardiogenic shock, and careful consideration should be given to the risk of [[stroke]] and bleeding  prior to [[IABP]] placement in this population.


====Left ventricular assist device placement====
====Left Ventricular Assist Device Placement====
In the setting of pronounced [[hypotension]] despite medical therapy and IABP placement, placement of a left [[ventricular assist device]] (which augments the pump-function of the heart) should be considered.  A ventricular assist device should only be placed in those patients in whom the cardiogenic shock is deemed to be reversible or if it is being used as a bridge option. <ref>Farrar DJ, Lawson JH, Litwak P, Cederwall G. Thoratec VAD system as a bridge to heart transplantation. J Heart Transplant. Jul-Aug 1990;9(4):415-22; discussion 422-3.</ref>
In the setting of pronounced [[hypotension]] despite medical therapy and IABP placement, placement of a left [[ventricular assist device]] (which augments the pump-function of the heart) should be considered.  A ventricular assist device should only be placed in those patients in whom the cardiogenic shock is deemed to be reversible or if it is being used as a bridge option.<ref>Farrar DJ, Lawson JH, Litwak P, Cederwall G. Thoratec VAD system as a bridge to heart transplantation. J Heart Transplant. Jul-Aug 1990;9(4):415-22; discussion 422-3.</ref>


====Coronary artery bypass graft (CABG) placement====
====Coronary Artery Bypass Graft (CABG) Placement====
CABG in this setting is associated with high rates of mortality and morbidity and is generally not performed if primary angioplasty can be performed.
CABG in this setting is associated with high rates of mortality and morbidity and is generally not performed if primary angioplasty can be performed.


===Mechanical ventilation===
===Mechanical Ventilation===
[[Mechanical ventilation]] is often required in patients with cardiogenic shock to assure adequate oxygenation.
[[Mechanical ventilation]] is often required in patients with cardiogenic shock to assure adequate oxygenation.


==ACC/AHA Guidelines (DO NOT EDIT)<ref name="pmid15339869">{{cite journal |author=Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK |title=ACC/AHA 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 (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) |journal=Circulation |volume=110 |issue=9 |pages=e82–292 |year=2004 |month=August |pmid=15339869 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15339869}}</ref>==
===Invasive Hemodynamic Monitoring===
Considering the importance of proper [[blood pressure]] assessment in patients in [[shock]], along with the fact that peripheral [[vasoconstriction]] may jeopardize [[blood pressure]] assessment through common manual [[sphygmomanometry]], all patients should have an indwelling [[arterial pressure]] [[catheter]] placed in order to gather more accurate measurements.<ref>{{cite book | last = Parrillo | first = Joseph | title = Critical care medicine principles of diagnosis and management in the adult | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2013 | isbn = 0323089291 }}</ref><ref name="pmid5336422">{{cite journal| author=Cohn JN| title=Blood pressure measurement in shock. Mechanism of inaccuracy in ausculatory and palpatory methods. | journal=JAMA | year= 1967 | volume= 199 | issue= 13 | pages= 118-22 | pmid=5336422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5336422  }} </ref> This method not only supplies continuous [[hemodynamic]] data, therefore allowing a beat-to-beat analysis, useful in evaluating the response to therapy, unlike other manual methods, but also allows for the collection of [[arterial blood gas]] samples.<ref name="Hollenberg2011">{{cite journal|last1=Hollenberg|first1=Steven M.|title=Vasoactive Drugs in Circulatory Shock|journal=American Journal of Respiratory and Critical Care Medicine|volume=183|issue=7|year=2011|pages=847–855|issn=1073-449X|doi=10.1164/rccm.201006-0972CI}}</ref><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> The most commonly used [[catheter]] is the ''flow-directed balloon-tipped [[pulmonary artery catheter]]'', which not only allows for [[cardiac output]] determination, as it is a good method for [[hemodynamic]] assessment of these patients, as well as continuous monitoring of [[pulmonary artery]] and [[central venous pressure]] and waveforms.<ref>{{cite book | last = Parrillo | first = Joseph | title = Critical care medicine principles of diagnosis and management in the adult | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2013 | isbn = 0323089291 }}</ref> With this device it is also possible to collect [[blood]] from the [[pulmonary artery]], therefore enabling determination of MVO<sub>2</sub>, in order to evaluate [[oxygen]] delivery to peripheral tissues and at the same time also helping in the [[diagnosis]] of [[left-to-right shunt]]s, usually associated with [[anatomic]] abnormalities. All these features make the ''flow-directed balloon-tipped [[pulmonary artery catheter]]'' a good tool for [[diagnosis]], management and monitoring of [[therapy]] of cardiogenic shock patients.<ref>{{cite book | last = Parrillo | first = Joseph | title = Critical care medicine principles of diagnosis and management in the adult | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2013 | isbn = 0323089291 }}</ref>


{{cquote|  
Other monitoring techniques include:<ref>{{cite book | last = Parrillo | first = Joseph | title = Critical care medicine principles of diagnosis and management in the adult | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2013 | isbn = 0323089291 }}</ref>
===Class I===


1. [[Intra-aortic balloon counterpulsation]] is recommended for [[STEMI]] patients when [[cardiogenic shock]] is not quickly reversed with pharmacological therapy. The [[IABP]] is a stabilizing measure for [[angiography]] and prompt [[revascularization]]. ''(Level of Evidence: B)''
*'''Oxymetry''' - although a useful tool in theory, since [[oxygen]] delivery will be directly affected by [[arterial oxygen saturation]], it has some limitations, such as affected results from ambient lights, [[hypothermia]] and dyshemoglobinemias. Also, motion artifacts, [[vasoconstriction]] and [[hypoperfusion]] in the [[shock]] state will jeopardize the readings.<ref name="pmid2024749">{{cite journal| author=Ralston AC, Webb RK, Runciman WB| title=Potential errors in pulse oximetry. III: Effects of interferences, dyes, dyshaemoglobins and other pigments. | journal=Anaesthesia | year= 1991 | volume= 46 | issue= 4 | pages= 291-5 | pmid=2024749 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2024749  }} </ref><ref name="pmid3688400">{{cite journal| author=Norley I| title=Erroneous actuation of the pulse oximeter. | journal=Anaesthesia | year= 1987 | volume= 42 | issue= 10 | pages= 1116 | pmid=3688400 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3688400  }} </ref><ref name="pmid2909323">{{cite journal| author=Pälve H, Vuori A| title=Pulse oximetry during low cardiac output and hypothermia states immediately after open heart surgery. | journal=Crit Care Med | year= 1989 | volume= 17 | issue= 1 | pages= 66-9 | pmid=2909323 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2909323  }} </ref>


2. Intra-arterial monitoring is recommended for the management of [[STEMI]] patients with [[cardiogenic shock]]. ''(Level of Evidence: C)''
*'''Near Infrared Spectroscopy (NIRS)''' - an innovative technique that allows for monitoring of tissue [[oxygenation]] by measuring regional tissue [[blood flow]], [[oxygen]] delivery and utilization. The near-infrared light passes through [[biological tissues]], such as [[muscle]] and [[skin]], and is absorbed by chromophores that is has passed through. The chromophores known to absorb the near-infrared light wavelength are [[cytochrome]] aa3, [[hemoglobin]] and [[myoglobin]], depending on the level of [[oxygenation]]. Since peripheral [[tissue]] [[hypoperfusion]] is a good marker of [[cardiovascular]] stress, NIRS presents itself as a good method to assess, in real-time, [[tissue]] [[perfusion]] throughout the evaluation and treatment periods, as well as during [[resuscitation]].<ref name="pmid11303156">{{cite journal| author=Cohn SM, Varela JE, Giannotti G, Dolich MO, Brown M, Feinstein A et al.| title=Splanchnic perfusion evaluation during hemorrhage and resuscitation with gastric near-infrared spectroscopy. | journal=J Trauma | year= 2001 | volume= 50 | issue= 4 | pages= 629-34; discussion 634-5 | pmid=11303156 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11303156  }} </ref><ref name="pmid10485597">{{cite journal| author=Beilman GJ, Groehler KE, Lazaron V, Ortner JP| title=Near-infrared spectroscopy measurement of regional tissue oxyhemoglobin saturation during hemorrhagic shock. | journal=Shock | year= 1999 | volume= 12 | issue= 3 | pages= 196-200 | pmid=10485597 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10485597  }} </ref><ref name="pmid10780595">{{cite journal| author=McKinley BA, Marvin RG, Cocanour CS, Moore FA| title=Tissue hemoglobin O2 saturation during resuscitation of traumatic shock monitored using near infrared spectrometry. | journal=J Trauma | year= 2000 | volume= 48 | issue= 4 | pages= 637-42 | pmid=10780595 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10780595  }} </ref><ref name="pmid8989194">{{cite journal| author=Rhee P, Langdale L, Mock C, Gentilello LM| title=Near-infrared spectroscopy: continuous measurement of cytochrome oxidation during hemorrhagic shock. | journal=Crit Care Med | year= 1997 | volume= 25 | issue= 1 | pages= 166-70 | pmid=8989194 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8989194  }} </ref><ref name="pmid9095123">{{cite journal| author=Cairns CB, Moore FA, Haenel JB, Gallea BL, Ortner JP, Rose SJ et al.| title=Evidence for early supply independent mitochondrial dysfunction in patients developing multiple organ failure after trauma. | journal=J Trauma | year= 1997 | volume= 42 | issue= 3 | pages= 532-6 | pmid=9095123 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9095123  }} </ref><ref name="pmid9932678">{{cite journal| author=Puyana JC, Soller BR, Zhang S, Heard SO| title=Continuous measurement of gut pH with near-infrared spectroscopy during hemorrhagic shock. | journal=J Trauma | year= 1999 | volume= 46 | issue= 1 | pages= 9-15 | pmid=9932678 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9932678  }} </ref>
*'''Advanced echocardiography in the ICU''' - particularly with the development of more advanced [[echocardiographic]] techniques, such as [[TEE]] and [[contrast]] [[echocardiography]], the inclusion of this [[noninvasive]] method in [[ICU]] has allowed for the decreased of more [[invasive]] techniques, such as [[pulmonary artery catheterization]]. This replacement has been seen due to the vast amount of important data that this method provides, such as assessment of of [[hemodynamic]] stability, [[cardiac output]], [[stroke volume]], [[preload]], detection of [[anatomic]] abnormalities, [[intravascular]] [[volume status]], [[pulmonary artery]] pressures, [[diagnosis]] of hemodynamically significant [[pulmonary embolism]], among others.<ref name="pmid8902376">{{cite journal| author=Porembka DT| title=Transesophageal echocardiography. | journal=Crit Care Clin | year= 1996 | volume= 12 | issue= 4 | pages= 875-918 | pmid=8902376 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8902376  }} </ref><ref name="pmid15302640">{{cite journal| author=ten Wolde M, Söhne M, Quak E, Mac Gillavry MR, Büller HR| title=Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism. | journal=Arch Intern Med | year= 2004 | volume= 164 | issue= 15 | pages= 1685-9 | pmid=15302640 | doi=10.1001/archinte.164.15.1685 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15302640  }} </ref>


3. Early [[revascularization]], either [[PCI]] or [[CABG]], is recommended for patients less than 75 years old with ST elevation or [[LBBB]] who develop shock within 36 hours of [[MI]] and who are suitable for [[revascularization]] that can be performed within 18 hours of shock unless further support is futile because of the patient’s wishes or contraindications/unsuitability for further invasive care. ''(Level of Evidence: A)''
==ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT)<ref name="pmid15339869">{{cite journal |author=Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK |title=ACC/AHA 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 (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) |journal=Circulation |volume=110 |issue=9 |pages=e82–292 |year=2004 |month=August |pmid=15339869 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15339869}}</ref>==


4. [[Fibrinolytic therapy]] should be administered to [[STEMI]] patients with [[cardiogenic shock]] who are unsuitable for further invasive care and do not have contraindications to [[fibrinolysis]]. ''(Level of Evidence: B)''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Intra-aortic balloon counterpulsation]] is recommended for [[STEMI]] patients when [[cardiogenic shock]] is not quickly reversed with pharmacological therapy. The [[IABP]] is a stabilizing measure for [[angiography]] and prompt [[revascularization]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Intra-arterial monitoring is recommended for the management of [[STEMI]] patients with [[cardiogenic shock]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Early [[revascularization]], either [[PCI]] or [[CABG]], is recommended for patients less than 75 years old with ST elevation or [[LBBB]] who develop shock within 36 hours of [[MI]] and who are suitable for [[revascularization]] that can be performed within 18 hours of shock unless further support is futile because of the patient’s wishes or contraindications/unsuitability for further invasive care. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' [[Fibrinolytic therapy]] should be administered to [[STEMI]] patients with [[cardiogenic shock]] who are unsuitable for further invasive care and do not have contraindications to [[fibrinolysis]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' [[Echocardiography]] should be used to evaluate mechanical complications unless these are assessed by invasive measures. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


5. [[Echocardiography]] should be used to evaluate mechanical complications unless these are assessed by invasive measures. ''(Level of Evidence: C)''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Pulmonary artery catheter monitoring can be useful for the management of [[STEMI]] patients with [[cardiogenic shock]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Early [[revascularization]], either [[PCI]] or [[CABG]], is reasonable for selected patients 75 years or older with ST elevation or [[LBBB]] who develop shock within 36 hours of [[MI]] and who are suitable for [[revascularization]] that can be performed within 18 hours of [[shock]]. Patients with good prior functional status who agree to invasive care may be selected for such an invasive strategy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


===Class IIa===
==References==
{{Reflist|2}}


1. Pulmonary artery catheter monitoring can be useful for the management of [[STEMI]] patients with [[cardiogenic shock]]. ''(Level of Evidence: C)''
[[Category:Needs overview]]
 
[[Category:Cardiology]]
2. Early [[revascularization]], either [[PCI]] or [[CABG]], is reasonable for selected patients 75 years or older with ST elevation or [[LBBB]] who develop shock within 36 hours of [[MI]] and who are suitable for [[revascularization]] that can be performed within 18 hours of [[shock]]. Patients with good prior functional status who agree to invasive care may be selected for such an invasive strategy. ''(Level of Evidence: B)''}}
[[Category:Cardiovascular diseases]]
 
[[Category:Medical emergencies]]
==References==
[[Category:Intensive care medicine]]
{{reflist|2}}
[[Category:Emergency medicine]]


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Latest revision as of 04:05, 3 January 2020

Cardiogenic Shock Microchapters

Home

Patient Information

Overview

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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Surgery

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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

Cardiogenic shock is considered an emergency and irrespectively to the therapeutic approach, the target goal of any therapy is prompt revascularization of ischemic myocardium. This should be achieved in the shortest timespan possible. There are two major categories of treatment for cardiogenic shock, the medical/conservative approach and the interventional approach. The ideal treatment combines both mechanisms, in which medical therapy, after restored filling pressures, allows hemodynamical stabilization of the patient, until interventional methods, that contribute to the reversal of the process leading to the shock state, may performed. The interventional approach may include PCI or coronary artery bypass graft surgery (CABG) and in both techniques the goal is not only reperfusion of the occluded coronary artery, but also prevention of vessel reoclusion. If there is no access to a cardiac catheterization facility, nor the possibility of transferring the patient to one within 90 minutes, then immediately thrombolytic therapy should be considered. Other important factors to increase the chances of a better outcome are: mechanical ventilation, in order to improve tissue oxygenation, and close monitoring of the therapeutic dosages, particularly of vasoactive drugs, since these have been associated with excess mortality due to toxicity effects. Also, it is recommended invasive hemodynamic monitoring, in order to monitor and guide the effects of the therapy as well as the overall status of the patient. The success of reperfusion is usually suggested by the relief of symptoms, restoration of hemodynamic parameters and electrical stability, as well as the reduction of at least 50% in the ST-segment on the EKG, in the case of a STEMI.

Surgery

Urgent Revascularizaiton

If the patient has an ST elevation myocardial infarction, then primary angioplasty should be considered to restore flow to the culprit artery. Consideration should also be given to restoration of flow in the non-culprit territories in the setting of cardiogenic shock.

Administration of streptokinase therapy to patients with cardiogenic shock has not been associated with an improvement in survival.[1] These studies, however, are older and are limited by the infrequent use of adjunctive PCI. If a patient is not deemed a candidate for primary angioplasty, then consideration should be given to fibrinolyitc administration.

Volume Management

The goal of managing the patient with cardiogenic shock is to optimize the filling of the left ventricle so that the starling relationship and mechanical performance and contractility of the heart is optimized. In the setting of acute MI, a pulmonary capillary wedge pressure of 18 to 20 mm Hg may optimize left ventricular filling. Filling pressures higher than this may lead to LV dilation, and poorer left ventricular function.

Pharmacologic Hemodynamic Support

If hypotension persists despite adequate left ventricular filling pressures, then the addition of vasconstrictors and/or inotropes is suggested. Hemodynamic monitoring is essential to assure that a target mean arterial pressure (MAP) of 60 to 65 mmHg is acheived to maintain perfusion to vital organs (brain, kidney, heart).

Selection of a Vasopressor or an Inotrope

Systolic Blood Pressure (SBP) > 80 mm Hg

Dobutamine may be preferable over dopamine at this blood pressure. Dopamine increase contractility and heart rate and thereby increases myocardial oxygen demand. Dobutamine reduces the systemic vascular resistance and may not increase oxygen demands as much as dopamine, and is preferable at this systolic blood pressure. Phosphodiesterase inhibitors (PDIs) such as milrinone and inamrinone (formerly known as amrinone) are not dependent upon the adrenoreceptor activity and patients may not develop tolerance, and they may be less likely to increase myocardial oxygen demands. However, the addition of a vasopressor is often required as these agents reduce preload and afterload. PDIs are more likely to be associated with tachyarrhythmias than dobutamine.

Systolic Blood Pressure (SBP) < 80 mm Hg

At systolic blood pressures < 80 mm Hg dopamine should be initiated first. The patient may not tolerate the vasodilating effects of dobutamine at this blood pressure. The initial dose of dopamine is 5 to 10 mcg/kg/min.

If the dopamine at doses of 20 mcg/kg/min does not achieve a MAP of 60-65 mm Hg, then norepinephrine can be added at an initial dose of 0.5 mcg/kg/min which can then be titrated up to 3.3 mcg/kg/min. Norepinephrine is avoided as a first line agent because of its adverse impact upon renal perfusion.

If norepinephrine does not generate a MAP of 60 mm Hg, then epinephrine can be added. Epinephrine increases both the stroke volume and heart rate, but is associated with lactic acidosis

Mechanical Support

Intra-aortic Balloon Placement

In the setting of acute MI, the placement of an intra-aortic balloon pump (which reduces workload for the heart, and improves perfusion of the coronary arteries) should be considered.

A recent meta-analysis of randomized trial data, however, challenges this common practice and class 1B recommendation.[2] In a meta-analysis of seven randomized trials enrolling 1009 patient, IABP placement in STEMI was not associated with an improvement in mortality or in left ventricular function but was associated with a higher rate of stroke and bleeding. When data from non-randomized cohort studies were evaluated in a meta-analysis (n=10,529 STEMI patients with cardiogenic shock), IABP placement was associated with an 18% relative risk reduction in 30 day mortality among patients treated with a fibrinolytic agent. This particular analysis is confounded by the fact that those patients in whom an IABP was placed underwent adjunctive percutaneous intervention (PCI) more frequently. In this non-randomized cohort analysis, IABP placement in patients undergoing primary angioplasty was associated with a 6% relative increase in mortality (p<0.0008). Thus, neither randomized nor observational data support IABP placement in the setting of primary PCI for cardiogenic shock, and careful consideration should be given to the risk of stroke and bleeding prior to IABP placement in this population.

Left Ventricular Assist Device Placement

In the setting of pronounced hypotension despite medical therapy and IABP placement, placement of a left ventricular assist device (which augments the pump-function of the heart) should be considered. A ventricular assist device should only be placed in those patients in whom the cardiogenic shock is deemed to be reversible or if it is being used as a bridge option.[3]

Coronary Artery Bypass Graft (CABG) Placement

CABG in this setting is associated with high rates of mortality and morbidity and is generally not performed if primary angioplasty can be performed.

Mechanical Ventilation

Mechanical ventilation is often required in patients with cardiogenic shock to assure adequate oxygenation.

Invasive Hemodynamic Monitoring

Considering the importance of proper blood pressure assessment in patients in shock, along with the fact that peripheral vasoconstriction may jeopardize blood pressure assessment through common manual sphygmomanometry, all patients should have an indwelling arterial pressure catheter placed in order to gather more accurate measurements.[4][5] This method not only supplies continuous hemodynamic data, therefore allowing a beat-to-beat analysis, useful in evaluating the response to therapy, unlike other manual methods, but also allows for the collection of arterial blood gas samples.[6][7] The most commonly used catheter is the flow-directed balloon-tipped pulmonary artery catheter, which not only allows for cardiac output determination, as it is a good method for hemodynamic assessment of these patients, as well as continuous monitoring of pulmonary artery and central venous pressure and waveforms.[8] With this device it is also possible to collect blood from the pulmonary artery, therefore enabling determination of MVO2, in order to evaluate oxygen delivery to peripheral tissues and at the same time also helping in the diagnosis of left-to-right shunts, usually associated with anatomic abnormalities. All these features make the flow-directed balloon-tipped pulmonary artery catheter a good tool for diagnosis, management and monitoring of therapy of cardiogenic shock patients.[9]

Other monitoring techniques include:[10]

ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT)[22]

Class I
"1. Intra-aortic balloon counterpulsation is recommended for STEMI patients when cardiogenic shock is not quickly reversed with pharmacological therapy. The IABP is a stabilizing measure for angiography and prompt revascularization. (Level of Evidence: B)"
"2. Intra-arterial monitoring is recommended for the management of STEMI patients with cardiogenic shock. (Level of Evidence: C)"
"3. Early revascularization, either PCI or CABG, is recommended for patients less than 75 years old with ST elevation or LBBB who develop shock within 36 hours of MI and who are suitable for revascularization that can be performed within 18 hours of shock unless further support is futile because of the patient’s wishes or contraindications/unsuitability for further invasive care. (Level of Evidence: A)"
"4. Fibrinolytic therapy should be administered to STEMI patients with cardiogenic shock who are unsuitable for further invasive care and do not have contraindications to fibrinolysis. (Level of Evidence: B)"
"5. Echocardiography should be used to evaluate mechanical complications unless these are assessed by invasive measures. (Level of Evidence: C)"
Class IIa
"1. Pulmonary artery catheter monitoring can be useful for the management of STEMI patients with cardiogenic shock. (Level of Evidence: C)"
"2. Early revascularization, either PCI or CABG, is reasonable for selected patients 75 years or older with ST elevation or LBBB who develop shock within 36 hours of MI and who are suitable for revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who agree to invasive care may be selected for such an invasive strategy. (Level of Evidence: B)"

References

  1. ↑ "Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI)". Lancet. 1 (8478): 397–402. 1986. PMID 2868337. Unknown parameter |month= ignored (help)
  2. ↑ Sjauw KD, Engström AE, Vis MM, van der Schaaf RJ, Baan J, Koch KT, de Winter RJ, Piek JJ, Tijssen JG, Henriques JP (2009). "A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines?". European Heart Journal. 30 (4): 459–68. doi:10.1093/eurheartj/ehn602. PMID 19168529. Unknown parameter |month= ignored (help)
  3. ↑ Farrar DJ, Lawson JH, Litwak P, Cederwall G. Thoratec VAD system as a bridge to heart transplantation. J Heart Transplant. Jul-Aug 1990;9(4):415-22; discussion 422-3.
  4. ↑ Parrillo, Joseph (2013). Critical care medicine principles of diagnosis and management in the adult. Philadelphia, PA: Elsevier/Saunders. ISBN 0323089291.
  5. ↑ Cohn JN (1967). "Blood pressure measurement in shock. Mechanism of inaccuracy in ausculatory and palpatory methods". JAMA. 199 (13): 118–22. PMID 5336422.
  6. ↑ Hollenberg, Steven M. (2011). "Vasoactive Drugs in Circulatory Shock". American Journal of Respiratory and Critical Care Medicine. 183 (7): 847–855. doi:10.1164/rccm.201006-0972CI. ISSN 1073-449X.
  7. ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
  8. ↑ Parrillo, Joseph (2013). Critical care medicine principles of diagnosis and management in the adult. Philadelphia, PA: Elsevier/Saunders. ISBN 0323089291.
  9. ↑ Parrillo, Joseph (2013). Critical care medicine principles of diagnosis and management in the adult. Philadelphia, PA: Elsevier/Saunders. ISBN 0323089291.
  10. ↑ Parrillo, Joseph (2013). Critical care medicine principles of diagnosis and management in the adult. Philadelphia, PA: Elsevier/Saunders. ISBN 0323089291.
  11. ↑ Ralston AC, Webb RK, Runciman WB (1991). "Potential errors in pulse oximetry. III: Effects of interferences, dyes, dyshaemoglobins and other pigments". Anaesthesia. 46 (4): 291–5. PMID 2024749.
  12. ↑ Norley I (1987). "Erroneous actuation of the pulse oximeter". Anaesthesia. 42 (10): 1116. PMID 3688400.
  13. ↑ Pälve H, Vuori A (1989). "Pulse oximetry during low cardiac output and hypothermia states immediately after open heart surgery". Crit Care Med. 17 (1): 66–9. PMID 2909323.
  14. ↑ Cohn SM, Varela JE, Giannotti G, Dolich MO, Brown M, Feinstein A; et al. (2001). "Splanchnic perfusion evaluation during hemorrhage and resuscitation with gastric near-infrared spectroscopy". J Trauma. 50 (4): 629–34, discussion 634-5. PMID 11303156.
  15. ↑ Beilman GJ, Groehler KE, Lazaron V, Ortner JP (1999). "Near-infrared spectroscopy measurement of regional tissue oxyhemoglobin saturation during hemorrhagic shock". Shock. 12 (3): 196–200. PMID 10485597.
  16. ↑ McKinley BA, Marvin RG, Cocanour CS, Moore FA (2000). "Tissue hemoglobin O2 saturation during resuscitation of traumatic shock monitored using near infrared spectrometry". J Trauma. 48 (4): 637–42. PMID 10780595.
  17. ↑ Rhee P, Langdale L, Mock C, Gentilello LM (1997). "Near-infrared spectroscopy: continuous measurement of cytochrome oxidation during hemorrhagic shock". Crit Care Med. 25 (1): 166–70. PMID 8989194.
  18. ↑ Cairns CB, Moore FA, Haenel JB, Gallea BL, Ortner JP, Rose SJ; et al. (1997). "Evidence for early supply independent mitochondrial dysfunction in patients developing multiple organ failure after trauma". J Trauma. 42 (3): 532–6. PMID 9095123.
  19. ↑ Puyana JC, Soller BR, Zhang S, Heard SO (1999). "Continuous measurement of gut pH with near-infrared spectroscopy during hemorrhagic shock". J Trauma. 46 (1): 9–15. PMID 9932678.
  20. ↑ Porembka DT (1996). "Transesophageal echocardiography". Crit Care Clin. 12 (4): 875–918. PMID 8902376.
  21. ↑ ten Wolde M, Söhne M, Quak E, Mac Gillavry MR, Büller HR (2004). "Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism". Arch Intern Med. 164 (15): 1685–9. doi:10.1001/archinte.164.15.1685. PMID 15302640.
  22. ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA 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 (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter |month= ignored (help)


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