Cardiogenic shock diagnostic criteria
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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]
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 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 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.[1]
Diagnostic Evaluation
- In clinical trials, particularly the SHOCK trial, cardiogenic shock in patients with acute myocardial infarction has been defined as:[2]
- Presence of ST-segment elevation, Q-wave infarction, new left bundle branch block, or posterior infarction with anterior ST-segment depression, complicated by shock due predominantly to left ventricular dysfunction.
- Hypotension (a systolic blood pressure of <90 mm Hg for at least 30 minutes or the need for supportive measures to maintain a systolic blood pressure of ≥90 mm Hg)
- End-organ hypoperfusion (cool extremities or a urine output of <30 ml per hour, and a heart rate of ≥60 beats per minute)
- Cardiac index of no more than 2.2 liters per minute per square meter of body-surface area (on support)
- Pulmonary capillary wedge pressure of at least 15 mm Hg
Diagnostic Criteria
Clinical Criteria
- Sustained hypotension for at least 30 minutes defined ad systolic blood pressure <90 mm Hg or 30 mm Hg below baseline in preexisting hypertension
- Clinical evidence of tissue hypoperfusion as manifested by oliguria, cyanosis, cool extremities, or altered mental status
- Presence of myocardial dysfunction following exclusion or correction of possible non-myocardial factors contributing to tissue hypoperfusion such as hypovolemia, hypoxia, arrhythmia, and acidosis[3][4][5]
Hemodynamic Criteria
- Sustained hypotension for at least 30 minutes defined ad systolic blood pressure <90 mm Hg or 30 mm Hg below baseline in preexisting hypertension
- Depressed cardiac index (<1.8 L/min/m2 of BSA without support or <2.0–2.2 L/min/m2 of BSA with support)
- Elevated pulmonary capillary wedge pressure (>15 mm Hg)
- Adequate filling pressure (left ventricular end-diastolic pressure >18 mm Hg or right ventricular end-diastolic pressure >10–15 mm Hg)
- Elevated arteriovenous oxygen difference (>5.5 mL/dL)[3][5][6][7][8]
References
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Hochman, JS.; Sleeper, LA.; Webb, JG.; Sanborn, TA.; White, HD.; Talley, JD.; Buller, CE.; Jacobs, AK.; Slater, JN. (1999). "Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock". N Engl J Med. 341 (9): 625–34. doi:10.1056/NEJM199908263410901. PMID 10460813. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 Califf, RM.; Bengtson, JR. (1994). "Cardiogenic shock". N Engl J Med. 330 (24): 1724–30. doi:10.1056/NEJM199406163302406. PMID 8190135. Unknown parameter
|month=ignored (help) - ↑ Hollenberg, SM.; Kavinsky, CJ.; Parrillo, JE. (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815. Unknown parameter
|month=ignored (help) - ↑ 5.0 5.1 Goldberg, RJ.; Gore, JM.; Alpert, JS.; Osganian, V.; de Groot, J.; Bade, J.; Chen, Z.; Frid, D.; Dalen, JE. (1991). "Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988". N Engl J Med. 325 (16): 1117–22. doi:10.1056/NEJM199110173251601. PMID 1891019. Unknown parameter
|month=ignored (help) - ↑ Forrester, JS.; Diamond, G.; Chatterjee, K.; Swan, HJ. (1976). "Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts)". N Engl J Med. 295 (24): 1356–62. doi:10.1056/NEJM197612092952406. PMID 790191. Unknown parameter
|month=ignored (help) - ↑ Forrester, JS.; Diamond, G.; Chatterjee, K.; Swan, HJ. (1976). "Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts)". N Engl J Med. 295 (25): 1404–13. doi:10.1056/NEJM197612162952505. PMID 790194. Unknown parameter
|month=ignored (help) - ↑ 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. Unknown parameter
|month=ignored (help)