Difference between revisions of "Cardiogenic shock pathophysiology"

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(Overview)
(The downward "Spiral" of Cardiogenic shock)
 
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==The downward "Spiral" of Cardiogenic shock==
 
==The downward "Spiral" of Cardiogenic shock==
  
*Cardiac dysfunction in patients with cardiogenic shock is usually initiated by myocardial infarction or ischemia.  
+
*[[Cardiac dysfunction]] in patients with [[cardiogenic shock]] is usually initiated by [[myocardial infarction]] or [[ischemia]].  
*The myocardial dysfunction resulting from ischemia worsens that ischemia, creating a downward spiral.  
+
*The [[myocardial dysfunction]] resulting from [[ischemia]] worsens that ischemia, creating a downward spiral.  
*When a critical mass of left ventricular myocardium is ischemic or necrotic and fails to pump, stroke volume and cardiac output decrease.
+
*When a critical mass of [[left ventricular]] [[myocardium]] is [[ischemic]] or [[necrotic]] and fails to pump, [[stroke volume]] and [[cardiac output]] decrease.
*Myocardial perfusion, which depends on the pressure gradient between the coronary arterial system and the left ventricle.
+
*Myocardial perfusion, which depends on the pressure gradient between the [[coronary]] arterial system and the [[left ventricle]].
 
*The duration of diastole, is compromised by hypotension and tachycardia. Which in turn, exacerbates ischemia.  
 
*The duration of diastole, is compromised by hypotension and tachycardia. Which in turn, exacerbates ischemia.  
*The increased ventricular diastolic pressures caused by pump failure further reduce coronary perfusion pressure, and the additional wall stress elevates myocardial oxygen requirements, further worsening ischemia.  
+
*The increased [[ventricular diastolic pressures]] caused by pump failure further reduce [[coronary perfusion pressure]], and the additional wall stress elevates myocardial oxygen requirements, further worsening ischemia.  
 
*Decreased cardiac output also compromises systemic perfusion, which can lead to lactic acidosis and further compromise of systolic performance.
 
*Decreased cardiac output also compromises systemic perfusion, which can lead to lactic acidosis and further compromise of systolic performance.
 
*The pathologic process begins with [[myocardial]] [[ischemia]] leading to an abnormal function of the [[cardiac muscle]].  
 
*The pathologic process begins with [[myocardial]] [[ischemia]] leading to an abnormal function of the [[cardiac muscle]].  

Latest revision as of 16:36, 16 January 2020

Cardiogenic Shock Microchapters

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Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Cardiogenic shock from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

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Treatment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2] Syed Musadiq Ali M.B.B.S.[3]

Overview

The pathophysiology of cardiogenic shock is complex and not fully understood. Ischemia to the myocardium causes derangement to both systolic and diastolic left ventricular function, resulting in a profound depression of myocardial contractility. This, in turn, leads to a potentially catastrophic and vicious spiral of reduced cardiac output and low blood pressure, perpetuating further coronary ischemia and impairment of contractility. Several physiologic compensatory processes ensue. These include:The activation of the sympathetic system leading to peripheral vasoconstriction which may improve coronary perfusion at the cost of increased afterload, and Tachycardia which increases myocardial oxygen demand and subsequently worsens myocardial ischemia.These compensatory mechanisms are subsequently counteracted by pathologic vasodilation that occurs from the release of potent systemic inflammatory markers such as interleukin-1, tumor necrosis factor a, and interleukin-6. Additionally, higher levels of nitric oxide and peroxynitrite are released, which also contribute to pathologic vasodilation and are known to be cardiotoxic. Unless interrupted by adequate treatment measures, this self-perpetuating cycle leads to global hypoperfusion and the inability to effectively meet the metabolic demands of the tissues, progressing to multiorgan failure and eventually death.

Pathophysiology

The downward "Spiral" of Cardiogenic shock

Right Ventricle Myocardial Infarction

Ventricular Septal and Free Wall Rupture

Inflammation and Hemodynamics

Iatrogenic Cardiogenic Shock

Histopathological Findings Of myocardial infarction and plaque rupture

http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Reynolds, H. R.; Hochman, J. S. (2008). "Cardiogenic Shock: Current Concepts and Improving Outcomes". Circulation. 117 (5): 686–697. doi:10.1161/CIRCULATIONAHA.106.613596. ISSN 0009-7322.
  2. 2.0 2.1 Hollenberg SM, Kavinsky CJ, Parrillo JE (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815.
  3. Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  4. Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  5. Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  6. Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  7. Bolli R, Marbán E (1999). "Molecular and cellular mechanisms of myocardial stunning". Physiol Rev. 79 (2): 609–34. PMID 10221990.
  8. Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  9. Bolli R (1998). "Basic and clinical aspects of myocardial stunning". Prog Cardiovasc Dis. 40 (6): 477–516. PMID 9647607.
  10. Marban E (1991). "Myocardial stunning and hibernation. The physiology behind the colloquialisms". Circulation. 83 (2): 681–8. PMID 1991384.
  11. Isner JM, Roberts WC (1978). "Right ventricular infarction complicating left ventricular infarction secondary to coronary heart disease. Frequency, location, associated findings and significance from analysis of 236 necropsy patients with acute or healed myocardial infarction". Am J Cardiol. 42 (6): 885–94. PMID 153103.
  12. 12.0 12.1 12.2 12.3 12.4 Ng, R.; Yeghiazarians, Y. (2011). "Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies". Journal of Intensive Care Medicine. 28 (3): 151–165. doi:10.1177/0885066611411407. ISSN 0885-0666.
  13. Reeder GS (1995). "Identification and treatment of complications of myocardial infarction". Mayo Clin Proc. 70 (9): 880–4. doi:10.1016/S0025-6196(11)63946-3. PMID 7643642.
  14. Lavie CJ, Gersh BJ (1990). "Mechanical and electrical complications of acute myocardial infarction". Mayo Clin Proc. 65 (5): 709–30. PMID 2190052.
  15. Jacobs AK, Leopold JA, Bates E, Mendes LA, Sleeper LA, White H; et al. (2003). "Cardiogenic shock caused by right ventricular infarction: a report from the SHOCK registry". J Am Coll Cardiol. 41 (8): 1273–9. PMID 12706920.
  16. Brookes, C.; Ravn, H.; White, P.; Moeldrup, U.; Oldershaw, P.; Redington, A. (1999). "Acute Right Ventricular Dilatation in Response to Ischemia Significantly Impairs Left Ventricular Systolic Performance". Circulation. 100 (7): 761–767. doi:10.1161/01.CIR.100.7.761. ISSN 0009-7322.
  17. 17.0 17.1 Figueras J, Alcalde O, Barrabés JA, Serra V, Alguersuari J, Cortadellas J; et al. (2008). "Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarction and cardiac rupture over a 30-year period". Circulation. 118 (25): 2783–9. doi:10.1161/CIRCULATIONAHA.108.776690. PMID 19064683.
  18. Becker RC, Gore JM, Lambrew C, Weaver WD, Rubison RM, French WJ; et al. (1996). "A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction". J Am Coll Cardiol. 27 (6): 1321–6. PMID 8626938.
  19. Becker RC, Hochman JS, Cannon CP, Spencer FA, Ball SP, Rizzo MJ; et al. (1999). "Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists: observations from the Thrombolysis and Thrombin Inhibition in Myocardial Infarction 9 Study". J Am Coll Cardiol. 33 (2): 479–87. PMID 9973029.
  20. Hochman JS, Buller CE, Sleeper LA, Boland J, Dzavik V, Sanborn TA; et al. (2000). "Cardiogenic shock complicating acute myocardial infarction--etiologies, management and outcome: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?". J Am Coll Cardiol. 36 (3 Suppl A): 1063–70. PMID 10985706.
  21. Thompson CR, Buller CE, Sleeper LA, Antonelli TA, Webb JG, Jaber WA; et al. (2000). "Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we use emergently revascularize Occluded Coronaries in cardiogenic shocK?". J Am Coll Cardiol. 36 (3 Suppl A): 1104–9. PMID 10985712.
  22. Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris DC, Kleiman NS; et al. (2000). "Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators". Circulation. 101 (1): 27–32. PMID 10618300.
  23. Radford MJ, Johnson RA, Daggett WM, Fallon JT, Buckley MJ, Gold HK; et al. (1981). "Ventricular septal rupture: a review of clinical and physiologic features and an analysis of survival". Circulation. 64 (3): 545–53. PMID 7020978.
  24. 24.0 24.1 Skehan JD, Carey C, Norrell MS, de Belder M, Balcon R, Mills PG (1989). "Patterns of coronary artery disease in post-infarction ventricular septal rupture". Br Heart J. 62 (4): 268–72. PMC 1277362. PMID 2803872.
  25. SWITHINBANK JM (1959). "Perforation of the interventricular septum in myocardial infarction". Br Heart J. 21: 562–6. PMC 1017615. PMID 13836145.
  26. Cohn, Lawrence (2012). Cardiac surgery in the adult. New York: McGraw-Hill Medical. ISBN 978-0-07-163310-9.
  27. Oliva PB, Hammill SC, Edwards WD (1993). "Cardiac rupture, a clinically predictable complication of acute myocardial infarction: report of 70 cases with clinicopathologic correlations". J Am Coll Cardiol. 22 (3): 720–6. PMID 8354804.
  28. 28.0 28.1 28.2 Slater J, Brown RJ, Antonelli TA, Menon V, Boland J, Col J; et al. (2000). "Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?". J Am Coll Cardiol. 36 (3 Suppl A): 1117–22. PMID 10985714.
  29. Figueras J, Cortadellas J, Soler-Soler J (2000). "Left ventricular free wall rupture: clinical presentation and management". Heart. 83 (5): 499–504. PMC 1760810. PMID 10768896.
  30. Cohn, Lawrence (2012). Cardiac surgery in the adult. New York: McGraw-Hill Medical. ISBN 007163312X.
  31. Cohn, Lawrence (2012). Cardiac surgery in the adult. New York: McGraw-Hill Medical. ISBN 007163312X.
  32. Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD; et al. (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.
  33. Picard MH, Davidoff R, Sleeper LA, Mendes LA, Thompson CR, Dzavik V; et al. (2003). "Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock". Circulation. 107 (2): 279–84. PMID 12538428.
  34. Kohsaka S, Menon V, Lowe AM, Lange M, Dzavik V, Sleeper LA; et al. (2005). "Systemic inflammatory response syndrome after acute myocardial infarction complicated by cardiogenic shock". Arch Intern Med. 165 (14): 1643–50. doi:10.1001/archinte.165.14.1643. PMID 16043684.
  35. Hochman, J. S. (2003). "Cardiogenic Shock Complicating Acute Myocardial Infarction: Expanding the Paradigm". Circulation. 107 (24): 2998–3002. doi:10.1161/01.CIR.0000075927.67673.F2. ISSN 0009-7322.
  36. Brunkhorst FM, Clark AL, Forycki ZF, Anker SD (1999). "Pyrexia, procalcitonin, immune activation and survival in cardiogenic shock: the potential importance of bacterial translocation". Int J Cardiol. 72 (1): 3–10. PMID 10636626.
  37. Hasdai, David. (2002). Cardiogenic shock : diagnosis and treatmen. Totowa, N.J.: Humana Press. ISBN 1-58829-025-5.
  38. Neumann, F.-J.; Ott, I.; Gawaz, M.; Richardt, G.; Holzapfel, H.; Jochum, M.; Schomig, A. (1995). "Cardiac Release of Cytokines and Inflammatory Responses in Acute Myocardial Infarction". Circulation. 92 (4): 748–755. doi:10.1161/01.CIR.92.4.748. ISSN 0009-7322.
  39. Shah, A (2000). "Inducible nitric oxide synthase and cardiovascular disease". Cardiovascular Research. 45 (1): 148–155. doi:10.1016/S0008-6363(99)00316-8. ISSN 0008-6363.
  40. Feng Q, Lu X, Jones DL, Shen J, Arnold JM (2001). "Increased inducible nitric oxide synthase expression contributes to myocardial dysfunction and higher mortality after myocardial infarction in mice". Circulation. 104 (6): 700–4. PMID 11489778.
  41. Cotter G, Kaluski E, Blatt A, Milovanov O, Moshkovitz Y, Zaidenstein R; et al. (2000). "L-NMMA (a nitric oxide synthase inhibitor) is effective in the treatment of cardiogenic shock". Circulation. 101 (12): 1358–61. PMID 10736276.
  42. Kaluski E, Hendler A, Blatt A, Uriel N (2006). "Nitric oxide synthase inhibitors in post-myocardial infarction cardiogenic shock--an update". Clin Cardiol. 29 (11): 482–8. PMID 17133844.
  43. Ferdinandy P, Danial H, Ambrus I, Rothery RA, Schulz R (2000). "Peroxynitrite is a major contributor to cytokine-induced myocardial contractile failure". Circ Res. 87 (3): 241–7. PMID 10926876.
  44. Geppert A, Dorninger A, Delle-Karth G, Zorn G, Heinz G, Huber K (2006). "Plasma concentrations of interleukin-6, organ failure, vasopressor support, and successful coronary revascularization in predicting 30-day mortality of patients with cardiogenic shock complicating acute myocardial infarction". Crit Care Med. 34 (8): 2035–42. doi:10.1097/01.CCM.0000228919.33620.D9. PMID 16775569.
  45. Rudiger A, Gasser S, Fischler M, Hornemann T, von Eckardstein A, Maggiorini M (2006). "Comparable increase of B-type natriuretic peptide and amino-terminal pro-B-type natriuretic peptide levels in patients with severe sepsis, septic shock, and acute heart failure". Crit Care Med. 34 (8): 2140–4. doi:10.1097/01.CCM.0000229144.97624.90. PMID 16763507.
  46. Granger CB, Mahaffey KW, Weaver WD, Theroux P, Hochman JS, Filloon TG; et al. (2003). "Pexelizumab, an anti-C5 complement antibody, as adjunctive therapy to primary percutaneous coronary intervention in acute myocardial infarction: the COMplement inhibition in Myocardial infarction treated with Angioplasty (COMMA) trial". Circulation. 108 (10): 1184–90. doi:10.1161/01.CIR.0000087447.12918.85. PMID 12925454.
  47. APEX AMI Investigators. Armstrong PW, Granger CB, Adams PX, Hamm C, Holmes D; et al. (2007). "Pexelizumab for acute ST-elevation myocardial infarction in patients undergoing primary percutaneous coronary intervention: a randomized controlled trial". JAMA. 297 (1): 43–51. doi:10.1001/jama.297.1.43. PMID 17200474.
  48. De Backer D, Creteur J, Dubois MJ, Sakr Y, Vincent JL (2004). "Microvascular alterations in patients with acute severe heart failure and cardiogenic shock". Am Heart J. 147 (1): 91–9. PMID 14691425.
  49. De Backer D, Creteur J, Preiser JC, Dubois MJ, Vincent JL (2002). "Microvascular blood flow is altered in patients with sepsis". Am J Respir Crit Care Med. 166 (1): 98–104. PMID 12091178.
  50. Trzeciak S, Dellinger RP, Parrillo JE, Guglielmi M, Bajaj J, Abate NL; et al. (2007). "Early microcirculatory perfusion derangements in patients with severe sepsis and septic shock: relationship to hemodynamics, oxygen transport, and survival". Ann Emerg Med. 49 (1): 88–98, 98.e1–2. doi:10.1016/j.annemergmed.2006.08.021. PMID 17095120.
  51. Babaev A, Frederick PD, Pasta DJ, Every N, Sichrovsky T, Hochman JS; et al. (2005). "Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock". JAMA. 294 (4): 448–54. doi:10.1001/jama.294.4.448. PMID 16046651.
  52. Jeger, R. V. (2006). "Emergency revascularization in patients with cardiogenic shock on admission: a report from the SHOCK trial and registry". European Heart Journal. 27 (6): 664–670. doi:10.1093/eurheartj/ehi729. ISSN 0195-668X.
  53. Meine TJ, Roe MT, Chen AY, Patel MR, Washam JB, Ohman EM; et al. (2005). "Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative". Am Heart J. 149 (6): 1043–9. doi:10.1016/j.ahj.2005.02.010. PMID 15976786.
  54. "ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58,050 patients with suspected acute myocardial infarction. ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group". Lancet. 345 (8951): 669–85. 1995. PMID 7661937.
  55. "Indications for ACE inhibitors in the early treatment of acute myocardial infarction: systematic overview of individual data from 100,000 patients in randomized trials. ACE Inhibitor Myocardial Infarction Collaborative Group". Circulation. 97 (22): 2202–12. 1998. PMID 9631869.
  56. Chen ZM, Pan HC, Chen YP, Peto R, Collins R, Jiang LX; et al. (2005). "Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial". Lancet. 366 (9497): 1622–32. doi:10.1016/S0140-6736(05)67661-1. PMID 16271643. Review in: ACP J Club. 2006 May-Jun;144(3):58-9 Review in: Evid Based Med. 2006 Jun;11(3):82-3



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