Cardiogenic shock resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, M.D. [2]

Definition

It is a state of end-organ hypoperfusion due cardiac failure leading to hemodynamic changes for 30 mins or more which is not due to hypovolemia or any other rapidly correctable causes:

• SBP < 80 mmHg or MAP < 30 mmHg than baseline
• Cardiac index ( CI ) < 1.8 L.Min^-1·M^-2 without vasopressors support or CI 2.0 to 2.2 L.Min^-1·M^-2 with vasopressors support.
• Elevated filling pressures LVEDP > 18 mmHg, RVEDP > 10 mmHg

Causes

Common Causes

• Cardiogenic shock

• Pump problems: LV failure mainly in anterior wall MI (the most common cause) and cardiomyopathy post-MI.
• Mechanical failure: Ventricular septal rupture, contained free wall rupture, and papillary muscle rupture. Mechanical problems are strongly suspected in non anterior MI. However cardiac tamponade, tension pneumothorax) and aortic stenosis are recently considered as obstructive shock.
• Electrical failure: Most commonly due toVF or VT and AF.

Prognosis

• Cardiogenic shock occurs in 8% of hospitalized STEMI patient with a mortality rate of 50-60% within 30 days.
• The only way to prevent CS is an early reperfusion therapy for MI

Management

Shock

ABCD Airway / O2 / 2 wide bore IV access / 12-lead ECG / focused H&P / CXR

ECG evidence of STEMI †

ECG inconclusive

ECG: -ve Clinical history of HF

STEMI

Echocardiography r/o Acute valvular lesions

Heart failure

Echocardiography to associated valvular causes ††

Echocardiography r/o Acute valvular

lesions

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† New ST elevation at the J point in at least 2 contiguous leads of 2 mm in men or 1.5 mm in women in leads V2-V3 and/or of 1 mm in other contiguous chest leads or the limb leads.

†† Early echocardiography should be done before PCI as long as the patient is not crashing, as it may change the treatment course.

Do's

• Transfer the STEMI patients with cardiogenic shock to PCI irrespective to time delay from time of presentation.
• Cardiogenic shock occurs in 5-8% of hospitalized STEMI patient.
• MI with LV failure is still the most common cause of the cardinogenic shock.
• Cardiac Echocardiography (Transthoracic) is helpful to rule out mechanical problems when the initial ECG findings are not conclusive or when the cardiogenic shock occurs with the first non anterior MI.
• Echocardiography should be performed early before PCI unless the diagnosis is extensive anterior MI and the patient is undergoing prompt percutaneous coronary intervention (PCI).