Cardiogenic Shock

Cardiogenic Shock ¶

1. Persistent hypotension 
    - (SBP <90 mmHg or MAP below baseline)
2. Cardiac Index <1.8 L/min/m^2 w/o support 
    - (<2.2 L/min/m^2 with support)
3. Adequate or elevated filling pressure 
    - (LVEDP >18 mmHg, RVEDP >10 mmHg)

Etiology¶

Ischemic
- Acute MI most commonly
- Impella in STEMI
Valve related
- Acute Aortic or Mitral Regurgitation
Rate Related
Cardiomyopathy
Toxicologic

Management ¶

Contemporary Management
Figure out etiology
- Valve related
- Ischemic
  - Impella in STEMI
- Rate Related
- Cardiomyopathy
- Toxicologic
Inotropic Therapy
- Milrinone = Dobutamine
- Use in hypotension, endo-organ hypoperfusion, shock
  - Generally, presents with hypoperfusion (reduced urine output)
- If due to contractile failure
  - Dobutamine + Norepinephrine to get MAP ≥65 w/ Mechanical circulatory support
    - Intra-aortic Balloon Counter Pulsation
- Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial
Pressors if needed for MAP > 65
- IV Vasopressor (norepinephrine)
- Levophed > Dopamine
  - Useful in Pulmonary congestion for rapid dyspnea relief if preserved Blood pressure
- Epinephrine is good too but more arrhythmogenic
Shock Centers

Mechanical Cardiac Support (MCS)¶

Indications for MCS
- Cardiogenic shock due to
  - Acute myocardial infarction and related mechanical complications
  - Acute decompensated heart failure
  - Acute myocarditis
  - Post-cardiotomy shock
  - Acute rejection post-cardiac transplant with hemodynamic compromise
- High-risk interventions
  - Percutaneous coronary intervention
  - Ventricular tachycardia ablation
- Bridge to LVAD or transplant
- Right ventricular failure

Differences in MCS ¶

Impella
- Decreases PCWP
- Increases coronary blood flow, reduces infarct size
- Works independently of LV function and cardiac rhythm
- Impella 2.5
  - CO: 2.5-4 L/min
- Impella 5
  - CO: 5 L/min
  - Requires surgical cutdown
- Notes
  - Wean to P2, pull from LV on P2, change to P0 and remove
  - Set to P2 to adjust

Courtesy of Ouweneel, D. M., Claessen, B. E., Sjauw, K. D., & Henriques, J. P. (2015). The Role of Percutaneous Haemodynamic Support in High-risk Percutaneous Coronary Intervention and Cardiogenic Shock. Interventional cardiology (London, England), 10(1), 39–44. https://doi.org/10.15420/icr.2015.10.1.39

Examples¶

The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery