Cardiogenic Shock

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Contents 1 Introduction 2 Etiology 3 Pathology 4 Laboratory 5 Management 6 More General Terms 7 Additional Terms 8 References

Introduction

• Failure to maintain adequate perfusion of vital organs secondary to impaired myocardial function.

Etiology

• myocardial infarction
• hemodynamically significant arrhythmias

• tachyarrhythmias

• ventricular tachycardia
• supraventricular tachycardia

• bradyarrhythmias

• cardiomyopathy
• acute valvular regurgitation ( papillary muscle rupture)
• acute ventricular septal defect (post MI)
• severe valvular stenosis

• aortic stenosis
• mitral stenosis
• subaortic stenosis

• acute coronary vasospasm

• Prinzmetal's angina
• cocaine

• rupture of free ventricular wall
• congenital heart disease with increased cardiac workload

Pathology

• elevated intracardiac pressure

• high cardiac filling pressures
• pulmonary artery wedge pressure > 18 torr

• depressed cardiac output

• cardiac index < 2.0 liters/min/m2

• increased systemic vascular resistance
• decreased mean arterial blood pressure - < 60 torr

Laboratory

• echocardiography
• cardiac catheterization

Management

• initial goal is to maintain

• systemic blood pressure
• cardiac output
• myocardial perfusion

• volume expansion
• inotropic agents

• dobutamine: also causes peripheral vasodilation
• dopamine
• norepinephrine may be most prudent choice [4]
• controversy over which agent 1st line [4]

• identify & treat precipitating factors
• intra-aortic balloon counterpulsation
• PCI vs CAPG (early) [see SHOCK trial]

More General Terms

• shock

Additional Terms

• dobutamine (Dobutrex)
• Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial

References

1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 135-36
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 211-214
3. Medical Knowledge Self Assessment Program (MKSAP) 14, American College of Physicians, Philadelphia 2006
4. De Backer D et al Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 2010 Mar 4; 362:779 PMID: [1]
   - Levy JH. Treating shock - Old drugs, new ideas. N Engl J Med 2010 Mar 4; 362:841. PMID: [2]

cardiogenic shock