Cardiogenic Shock

SHOCK= Inadequate Tissue Perfusion

Mechanisms:

Inadequate oxygen delivery Release of inflammatory mediators Further microvascular changes, compromised blood flow and further cellular hypoperfusion

Clinical Manifestations:

Hypotension Multiple organ failure i.e. altered conscious level and reduced urinary output

Types
1. 2. 3. 4. 5. 6.

Cardiogenic shock (associated with cardiac pathology) Hypovolemic shock (caused by inadequate blood volume) Anaphylactic shock (caused by allergic reaction) Septic shock (associated with infections) Neurogenic shock(caused by damage to the nervous system) Metabolic ( associated with metabolic acidosis, hypothyroidism,
addisonian crisis)

Cardiogenic shock

Cardiogenic shock is defined as sustained hypotension with tissue hypoperfusion despite adequate left ventricular filling pressure, secondary to some cardiac pathology.

Cardiogenic Shock Clinical Parameters

Hypotension i.e., systolic BP less than 90 mm of Hg , weak and thready pulse Elevated JVP Cold and clammy skin Altered mental status Reduce urine output

Hemodynamic Parameters

Systemic Vascular Resistance (SVR) Cardiac Output (CO) Mixed Venous Oxygen Saturation (SvO2) Pulmonary Capillary Wedge Pressure (PCWP) Central Venous Pressure (CVP)

Differentiating Types of Shock

Cardiogenic Shock

Etiologies Pathophysiology Clinical/Hemodynamic Characteristics Treatment Options

Etiologies
1.

Acute extensive myocardial infarction/ischemia

Other conditions

Refractory sustained tachyarrhythmias

2.
3.

VSR
Papillary muscle/chordal rupture- severe MR

Acute fulminant myocarditis

cardiomyopathies Pulmonary embolism Severe valvular heart disease and acute regurgitations

4.

Ventricular free wall rupture with subacute tamponade

RV infarction

5.

Pathophysiology

Initial evaluation

EKG CXR Echocardiography Blood biochemistry , biomarkers Hemodynamic measurements (swan ganz catheter)

Treatment

Inotropes or vasopressors Intra-aortic Balloon Pump (IABP) Fibrinolytics Revascularization: CABG/PCI

Refractory shock: ventricular assist device, cardiac transplantation

Inotropes do not change outcome

Dopamine
1 stimulant which increases myocardial contractility through preferential stimulation of myocardial B1-adrenergic receptors DOSE <2 renal vascular dilation <2-10 +chronotropic/inotropic (beta effects) >10 vasoconstriction (alpha effects)

Dobutamine

Positive inotrope, peripheral vasodilater, arrhythmogenic at higher doses

synthetic catecholamine increases myocardial contractility through preferential stimulation of myocardial B1-adrenergic receptors. Dobutamine has less chronotropic effect than does dopamine and typically does not cause significant changes in heart rate when the dose is less than 15 g/kg/min

Norepinephrine

vasoconstriction, inotropic stimulant. Should only be used for refractory hypotension with dec SVR. Norepinephrine is a powerful 1 stimulant that results in arterial vasoconstriction and is 1-stimulant that increases inotropy.

Other drugs

Phosphodiesterase inhibitors, such as milrinone and amrinone Digoxin Levosimendan, a calcium-sensitizing drug with positive inotropic and vasodilating properties Arginine vasopressin (AVP) a potent vasopressor hormone

Nitric oxide synthase inhibitors (LNNMA and LNAME) block the synthesis of nitric oxide Nesiritide

IABP(Intraortic balloon pump) is a bridging measure

IABP
1. 2.

3.

Augments coronary blood flow in diastole Balloon collapse in systole creates a vacuum effect decreases afterload Decrease myocardial oxygen demand

Indication for IABP

Definitive treatment

PCI Surgical revascularization Surgical repair of cardiac defect

SHOCK trial

Hochman J et al. N Engl J Med 1999;341:625-634

SHOCK 6 years later

Kaplan-Meier Long-term Survival of All Patients and Those Discharged Alive Following Hospitalization

Hochman, J. S. et al. JAMA 2006;295:2511-2515.

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Normal Values
Right Atrial Pressure, CVP Mean 0-6mmHg 15-30mmHg 4-12mmHg 9-19mmHg 4-12mmHg 4-8 L/min >70%

Pulmonary Systolic Artery Pressure End-diastolic mean PCWP Mean Cardiac Output Mixed Venous O2 Sat

SVR

800-1200