Cardiogenic shock secondary prevention
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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]
Overview
Cardiogenic shock is considered an emergency and irrespectively to the therapeutic approach, the target goal of any therapy is prompt revascularization of ischemic myocardium. This should be achieved in the shortest timespan possible. There are two major categories of treatment for cardiogenic shock, the medical/conservative approach and the interventional approach. The ideal treatment combines both mechanisms, in which medical therapy, after restored filling pressures, allows hemodynamical stabilization of the patient, until interventional methods, that contribute to the reversal of the process leading to the shock state, may performed. The interventional approach may include PCI or coronary artery bypass graft surgery (CABG) and in both techniques the goal is not only reperfusion of the occluded coronary artery, but also prevention of vessel reoclusion. If there is no access to a cardiac catheterization facility, nor the possibility of transferring the patient to one within 90 minutes, then immediately thrombolytic therapy should be considered.[1] Other important factors to increase the chances of a better outcome are: mechanical ventilation, in order to improve tissue oxygenation, and close monitoring of the therapeutic dosages, particularly of vasoactive drugs, since these have been associated with excess mortality due to toxicity effects.[2][3] Also, it is recommended invasive hemodynamic monitoring, in order to monitor and guide the effects of the therapy as well as the overall status of the patient. The success of reperfusion is usually suggested by the relief of symptoms, restoration of hemodynamic parameters and electrical stability, as well as the reduction of at least 50% in the ST-segment on the EKG, in the case of a STEMI.[1][4]
Secondary prevention
Attending to the definition of secondary prevention, namely the methods or techniques used in order to avoid the development of symptoms of an already existent disease, and considering the fact that left ventricular failure, following MI is the most common cause of cardiogenic shock, these patients should undergo secondary prevention of STEMI. This is a crucial part of the management of STEMI patients, regardless of their gender.[5][6][7][8] Since atherosclerotic disease is commonly found in multiple vessels in STEMI patients, these should be evaluated for possible signs or symptoms of peripheral vascular or cerebrovascular disease.[5] As secondary prevention, these patients have the following indications:[5]
- Education before discharging the patient
- Lipid management
- Weight management
- Smoking cessation
- Antiplatelet therapy
- RAAS inhibition
- Beta-blockage
- Blood pressure monitoring
- Control of diabetes
- Hormone therapy in women
- Warfarin therapy
- Exercise/physical activity
- Antioxidant intake
References
- ↑ 1.0 1.1 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.
- ↑ TRIUMPH Investigators. Alexander JH, Reynolds HR, Stebbins AL, Dzavik V, Harrington RA; et al. (2007). "Effect of tilarginine acetate in patients with acute myocardial infarction and cardiogenic shock: the TRIUMPH randomized controlled trial". JAMA. 297 (15): 1657–66. doi:10.1001/jama.297.15.joc70035. PMID 17387132.
- ↑ Sakr Y, Reinhart K, Vincent JL, Sprung CL, Moreno R, Ranieri VM; et al. (2006). "Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study". Crit Care Med. 34 (3): 589–97. doi:10.1097/01.CCM.0000201896.45809.E3. PMID 16505643.
- ↑ Hochman, Judith (2009). Cardiogenic shock. Chichester, West Sussex, UK Hoboken, NJ: Wiley-Blackwell. ISBN 9781405179263.
- ↑ 5.0 5.1 5.2 Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M; et al. (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)". Circulation. 110 (5): 588–636. doi:10.1161/01.CIR.0000134791.68010.FA. PMID 15289388.
- ↑ Smith, S. C.; Blair, S. N.; Bonow, R. O.; Brass, L. M.; Cerqueira, M. D.; Dracup, K.; Fuster, V.; Gotto, A.; Grundy, S. M.; Miller, N. H.; Jacobs, A.; Jones, D.; Krauss, R. M.; Mosca, L.; Ockene, I.; Pasternak, R. C.; Pearson, T.; Pfeffer, M. A.; Starke, R. D.; Taubert, K. A. (2001). "AHA/ACC Guidelines for Preventing Heart Attack and Death in Patients With Atherosclerotic Cardiovascular Disease: 2001 Update: A Statement for Healthcare Professionals From the American Heart Association and the American College of Cardiology". Circulation. 104 (13): 1577–1579. doi:10.1161/hc3801.097475. ISSN 0009-7322.
- ↑ Mosca, L. (2004). "Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women". Circulation. 109 (5): 672–693. doi:10.1161/01.CIR.0000114834.85476.81. ISSN 0009-7322.
- ↑ Dalal H, Evans PH, Campbell JL (2004). "Recent developments in secondary prevention and cardiac rehabilitation after acute myocardial infarction". BMJ. 328 (7441): 693–7. doi:10.1136/bmj.328.7441.693. PMC 381231. PMID 15031243.