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Cardiogenic Shock

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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

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Types

1. Cardiogenic shock (associated with cardiac pathology)

2. Hypovolemic shock (caused by inadequate blood volume)

3. Anaphylactic shock (caused by allergic reaction)

4. Septic shock (associated with infections)

5. Neurogenic shock(caused by damage to the nervous system)

6. Metabolic ( associated with metabolic acidosis, hypothyroidism,addisonian crisis)

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Cardiogenic shock

Cardiogenic shock is defined as sustained

hypotension with tissue hypoperfusiondespite adequate left ventricular fillingpressure, secondary to some cardiacpathology.

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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

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Hemodynamic Parameters

Systemic Vascular Resistance (SVR)

Cardiac Output (CO) Mixed Venous Oxygen Saturation (SvO2)

Pulmonary Capillary Wedge Pressure

(PCWP)

Central Venous Pressure (CVP)

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Differentiating Types of Shock

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Cardiogenic Shock

Etiologies

Pathophysiology Clinical/Hemodynamic Characteristics

Treatment Options

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Etiologies

1. Acute extensivemyocardialinfarction/ischemia

2. VSR

3. Papillary muscle/chordalrupture- severe MR

4. Ventricular free wallrupture with subacutetamponade

5. RV infarction

Other conditions

Refractory sustained

tachyarrhythmias

Acute fulminant myocarditis

cardiomyopathies

Pulmonary embolism

Severe valvular heartdisease and acuteregurgitations

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Pathophysiology

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Initial evaluation

EKG

CXR Echocardiography

Blood biochemistry , biomarkers

Hemodynamic measurements (swan ganzcatheter)

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Treatment

Inotropes or vasopressors

Intra-aortic Balloon Pump (IABP) Fibrinolytics

Revascularization: CABG/PCI

Refractory shock: ventricular assist device,cardiac transplantation

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Inotropes do not change

outcome

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Dopamine

1 stimulant which increases myocardialcontractility through preferentialstimulation of myocardial B1-adrenergicreceptors

DOSE

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Dobutamine

Positive inotrope, peripheral vasodilater,arrhythmogenic at higher doses

synthetic catecholamine increases myocardialcontractility through preferential stimulation ofmyocardial B1-adrenergic receptors. Dobutaminehas less chronotropic effect than does dopamine and

typically does not cause significant changes in heartrate when the dose is less than 15 g/kg/min

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Norepinephr ine

vasoconstriction, inotropic stimulant.

Should only be used for refractoryhypotension with dec SVR. Norepinephrine is a powerful 1 stimulant

that results in arterial vasoconstriction and is

1-stimulant that increases inotropy.

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Other drugs

Phosphodiesterase inhibitors, such as

milrinone and amrinone Digoxin

Levosimendan, a calcium-sensitizing drugwith positive inotropic and vasodilating

properties Arginine vasopressin (AVP) a potent

vasopressor hormone

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Nitric oxide synthase inhibitors (LNNMA

and LNAME) block the synthesis of nitricoxide

Nesiritide

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IABP(Intraortic balloon pump) is

a bridging measure

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IABP

1. Augments coronary blood flow in diastole

2. Balloon collapse in systole creates avacuum effect decreases afterload

3. Decrease myocardial oxygen demand

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Indication for IABP

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Definitive treatment

PCI

Surgical revascularization Surgical repair of cardiac defect

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SHOCK trial

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

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Copyright restrictions may apply.

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

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

SHOCK 6 years later

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Normal Values

Right Atrial

Pressure, CVP

Mean 0-6mmHg

PulmonaryArtery Pressure

Systolic

End-diastolic

mean

15-30mmHg

4-12mmHg

9-19mmHg

PCWP Mean 4-12mmHgCardiac Output 4-8 L/min

Mixed Venous

O2 Sat

>70%

SVR 800-1200