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Cardiogenic shock

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Cardiogenic shock
Ultrasound image after cardiogenic shock due to myocarditis[1]
SpecialtyCardiology
SymptomsFatigue, rapid heartbeat, shortness of breath, hypotension, sweating, chest pain, dizziness or lightheadedness, nausea, decreased level of consciousness[2]
ComplicationsWorsening of or causing heart failure and/or heart block, serious arrhythmias such as ventricular fibrillation, cor pulmonale, respiratory or kidney or liver dysfunction or failure, multiple organ dysfunction syndrome, cardiac arrest, death
CausesHeart attack, myocarditis, endocarditis, certain medications and substances[2]
Risk factorsHeart failure, old age, hypertension[2]
PrognosisFor patients where the cause is not due to a heart attack, the mortality rate is still relatively high, at about 60%; some progress has been made in treating CS when due to a heart attack, and the mortality rate is now somewhat lower for those with MI who survive and are treated rapidly with current therapies (February 2021)[3]

Cardiogenic shock (CS) is a medical emergency resulting from inadequate blood flow due to the dysfunction of the ventricles of the heart.[4][5][6][7][8] Signs of inadequate blood flow include low urine production (<30 mL/hour), cool arms and legs, and decreased level of consciousness. People may also have a severely low blood pressure and heart rate.

Causes of cardiogenic shock include cardiomyopathic, arrhythmic, and mechanical. CS is most commonly precipitated by acute myocardial infarction.[9] People can have combined types of shock.

Treatment of cardiogenic shock depends on the cause with the initial goals to improve blood flow to the body. This can be done in a number of ways—fluid resuscitation, blood transfusions, vasopressors, and ionotropes. If cardiogenic shock is due to a heart attack, attempts to open the heart's arteries may help. An intra-aortic balloon pump may improve matters until this can be done. Medications that improve the heart's ability to contract (positive inotropes) may help; however, it is unclear which is best and at present there is no convincing evidence supporting inotropic or vasodilating therapy to reduce mortality in hemodynamically unstable patients.[10] Norepinephrine may be better if the blood pressure is very low whereas dopamine or dobutamine may be more useful if only slightly low.[11] Cardiogenic shock is a condition that is difficult to fully reverse even with an early diagnosis. With that being said, early initiation of mechanical circulatory support, early percutaneous coronary intervention, inotropes, and heart transplantation may improve outcomes.[12][13][14][15][16] Care is directed to the dysfunctional organs (dialysis for the kidneys, mechanical ventilation for lungs dysfunction).[17]

Mortality rates have been decreasing in the United States. This is likely due to the rapid identification and treatment of the CS. Some studies have suggested that this possibly related to the increased use of coronary reperfusion strategies, like heart stents. Nonetheless, the mortality rates remain high.[18] Multi-organ failure is associated with higher rates of mortality.

Signs and symptoms

The presentation is the following:[citation needed]

Causes

Cardiogenic shock is caused by the failure of the heart to pump effectively. It is due to damage to the heart muscle, most often from a heart attack or myocardial contusion.[19] Other causes include abnormal heart rhythms, cardiomyopathy, heart valve problems, ventricular outflow obstruction (i.e. systolic anterior motion (SAM) in hypertrophic cardiomyopathy), or ventriculoseptal defects. It can also be caused by a sudden decompressurization (e.g. in an aircraft), where air bubbles are released into the bloodstream (Henry's law), causing heart failure.[4][5][6][7][8][20][21]

Diagnosis

Electrocardiogram

An electrocardiogram helps to establish the exact diagnosis and guides treatment, it may reveal:

Echocardiography

Echocardiography may show poor ventricular function, signs of PED, rupture of the interventricular septum, an obstructed outflow tract or cardiomyopathy.[citation needed]

  • Ultrasound showing cardiogenic shock due to myocarditis[1]
  • Ultrasound showing cardiogenic shock due to myocarditis[1]

Swan-Ganz catheter

The Swan–Ganz catheter or pulmonary artery catheter may assist in the diagnosis by providing information on the hemodynamics.[citation needed]

Biopsy

When cardiomyopathy is suspected as the cause of cardiogenic shock, a biopsy of heart muscle may be needed to make a definite diagnosis.[citation needed]

Cardiac index

If the cardiac index falls acutely below 2.2 L/min/m2, the person may be in cardiogenic shock.[citation needed]

Treatment

Depending on the type of cardiogenic shock, treatment involves infusion of fluids, or in shock refractory to fluids, inotropic medications. In case of an abnormal heart rhythm immediate synchronized cardioversion or anti-arrhythmic agents may be administered, e.g. adenosine.[citation needed]

Positive inotropic agents (such as dobutamine or milrinone), which enhance the heart's pumping capabilities, are used to improve the contractility and correct the low blood pressure. Should that not suffice an intra-aortic balloon pump (which reduces workload for the heart, and improves perfusion of the coronary arteries) or a left ventricular assist device (which augments the pump-function of the heart) can be considered. Mechanical ventilation or ECMO may be used to help stabilize people with severe or refractory cardiogenic shock until they can be given some type of definitive treatment, such as a ventricular assist device.[4][5][6] Finally, as a last resort, if the person is stable enough and otherwise qualifies, heart transplantation, or if not eligible an artificial heart, can be placed. These invasive measures are important tools—more than 50% of patients who do not die immediately due to cardiac arrest from a lethal abnormal heart rhythm and live to reach the hospital (who have usually experienced a severe acute myocardial infarction, which in itself still has a relatively high mortality rate), die within the first 24 hours. The mortality rate for those still living at time of admission who develop complications (among others, cardiac arrest or further abnormal heart rhythms, heart failure, cardiac tamponade, a ruptured or dissecting aneurysm, or another heart attack) from cardiogenic shock is even worse around 85%, especially without drastic measures such as ventricular assist devices or transplantation.[citation needed]

Cardiogenic shock may be treated with intravenous dobutamine, which acts on β1 receptors of the heart leading to increased contractility and heart rate.[22]

References

  1. ^ a b c "UOTW #7 – Ultrasound of the Week". Ultrasound of the Week. 30 June 2014. Retrieved 27 May 2017.
  2. ^ a b c "Cardiogenic shock – Symptoms and causes". Mayo Clinic. Retrieved 22 May 2020.
  3. ^ Schrage, Benedikt; Becher, Peter Moritz; Goßling, Alina; Savarese, Gianluigi; Dabboura, Salim; Yan, Isabell; Beer, Benedikt; Söffker, Gerold; Seiffert, Moritz; Kluge, Stefan; Kirchhof, Paulus; Blankenberg, Stefan; Westermann, Dirk (2021). "Temporal trends in incidence, causes, use of mechanical circulatory support and mortality in cardiogenic shock". ESC Heart Failure. 8 (2): 1295–1303. doi:10.1002/ehf2.13202. PMC 8006704. PMID 33605565.
  4. ^ a b c Rippe, James M.; Irwin, Richard S. (2003). Irwin and Rippe's intensive care medicine. Philadelphia: Lippincott Williams & Wilkins. ISBN 978-0-7817-3548-3. OCLC 53868338.[page needed]
  5. ^ a b c Marino, Paul L. (1998). The ICU book. Baltimore: Williams & Wilkins. ISBN 978-0-683-05565-8. OCLC 300112092.[page needed]
  6. ^ a b c Society of Critical Care Medicine. (2001). Fundamental Critical Care Support. Society of Critical Care Medicine. ISBN 978-0-936145-02-0. OCLC 48632566.[page needed]
  7. ^ a b Textbooks of Internal Medicine Harrison's Principles of Internal Medicine Archived 2012-08-04 at the Wayback Machine 16th Edition, The McGraw-Hill Companies, ISBN 0-07-140235-7Cecil Textbook of Medicine Archived 2010-06-16 at the Wayback Machine by Lee Goldman, Dennis Ausiello, 22nd Edition (2003), W. B. Saunders Company, ISBN 0-7216-9652-XThe Oxford Textbook of Medicine Archived 2006-09-23 at the Wayback Machine Edited by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth Edition (2003), Oxford University Press, ISBN 0-19-262922-0
  8. ^ a b Shock: An Overview Archived 2017-06-22 at the Wayback Machine PDF by Michael L. Cheatham, MD, Ernest F.J. Block, MD, Howard G. Smith, MD, John T. Promes, MD, Surgical Critical Care Service, Department of Surgical Education, Orlando Regional Medical Center Orlando, Florida
  9. ^ "UpToDate".
  10. ^ Uhlig, Konstantin; Efremov, Ljupcho; Tongers, Jörn; Frantz, Stefan; Mikolajczyk, Rafael; Sedding, Daniel; Schumann, Julia (November 5, 2020). "Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome". The Cochrane Database of Systematic Reviews. 2020 (11): CD009669. doi:10.1002/14651858.CD009669.pub4. ISSN 1469-493X. PMC 8094388. PMID 33152122.
  11. ^ Kanter, Joe; Deblieux, Peter (2014). "Pressors and Inotropes". Emergency Medicine Clinics of North America. 32 (4): 823–34. doi:10.1016/j.emc.2014.07.006. PMID 25441037.
  12. ^ Kataja, Anu; Tarvasmäki, Tuukka; Lassus, Johan; Cardoso, Jose; Mebazaa, Alexandre; Køber, Lars; Sionis, Alessandro; Spinar, Jindrich; Carubelli, Valentina; Banaszewski, Marek; Marino, Rossella; Parissis, John; Nieminen, Markku S.; Harjola, Veli-Pekka (2017). "The association of admission blood glucose level with the clinical picture and prognosis in cardiogenic shock – Results from the Card Shock Study". International Journal of Cardiology. 226: 48–52. doi:10.1016/j.ijcard.2016.10.033. hdl:10138/231345. PMID 27788389.
  13. ^ Basir, Mir B.; Schreiber, Theodore L.; Grines, Cindy L.; Dixon, Simon R.; Moses, Jeffrey W.; Maini, Brijeshwar S.; Khandelwal, Akshay K.; Ohman, E. Magnus; O'Neill, William W. (2017). "Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock". The American Journal of Cardiology. 119 (6): 845–851. doi:10.1016/j.amjcard.2016.11.037. PMID 28040188.
  14. ^ Bagate, François; Lellouche, Nicolas; Lim, Pascal; Moutereau, Stephane; Razazi, Keyvan; Carteaux, Guillaume; De Prost, Nicolas; Dubois-Randé, Jean-Luc; Brun-Buisson, Christian; Mekontso Dessap, Armand (2017). "Prognostic Value of Relative Adrenal Insufficiency During Cardiogenic Shock". SHOCK. 47 (1): 86–92. doi:10.1097/SHK.0000000000000710. PMID 27984534. S2CID 3651074.
  15. ^ Vergara, Ruben; Valenti, Renato; Migliorini, Angela; Cerisano, Giampaolo; Carrabba, Nazario; Giurlani, Letizia; Antoniucci, David (2017). "A New Risk Score to Predict Long-Term Cardiac Mortality in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock and Treated with Primary Percutaneous Intervention". The American Journal of Cardiology. 119 (3): 351–354. doi:10.1016/j.amjcard.2016.10.034. PMID 27884422.
  16. ^ Sarswat, Nitasha; Hollenberg, Steven M. (2015). "Cardiogenic Shock". Hospital Practice. 38 (1): 74–83. doi:10.3810/hp.2010.02.281. PMID 20469627. S2CID 32855274.
  17. ^ Simko, Lynn Coletta; Culleiton, Alicia L. (July 2019). "Cardiogenic shock with resultant multiple organ dysfunction syndrome". Nursing Critical Care. 14 (4): 26–33. doi:10.1097/01.CCN.0000565132.49413.54.
  18. ^ "UpToDate".
  19. ^ International Trauma Life Support for Emergency Care Providers (8 ed.). Pearson Education Limited. 2018. pp. 172–173. ISBN 978-1292-17084-8.
  20. ^ Cardiogenic shock Archived 2017-07-23 at the Wayback Machine Department of Anaesthesia and Intensive Care of The Chinese University of Hong Kong
  21. ^ Introduction to management of shock for junior ICU trainees and medical students Archived 2017-07-27 at the Wayback Machine Department of Anaesthesia and Intensive Care of The Chinese University of Hong Kong
  22. ^ Rang and Dale's Pharmacology, H. P. Rang, M. M. Dale, J. M. Ritter, R. J. Flower, Churchhill Livingstone, Elsevier, 6th Edition[page needed]
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