Management of cardiogenic shock: a narrative review

Laghlam, D., Benghanem, S., Ortuno, S. et al. Management of cardiogenic shock: a narrative review. Ann. Intensive Care 14, 45 (2024). https://doi.org/10.1186/s13613-024-01260-y

Summary of "Management of Cardiogenic Shock: A Narrative Review"

Abstract

Cardiogenic shock (CS) is marked by low cardiac output and prolonged tissue hypoperfusion, which can lead to organ dysfunction and death. Despite recent therapeutic advances, CS remains challenging to manage and has a high short-term mortality rate. Early diagnosis and a multidisciplinary management approach have been shown to improve outcomes. This review discusses evidence-based practices for managing ischemic and non-ischemic CS and the multi-organ support required for these critically ill patients.

Introduction

CS is a severe condition caused by primary cardiac dysfunction, leading to peripheral hypoperfusion and organ dysfunction. The most common cause is acute myocardial infarction (AMI), but other causes include myocarditis, right ventricular failure, and valvular heart disease. Despite advances in cardiovascular care, the 30-day survival rate for CS patients remains around 50%.

Definitions and Classifications CS is characterized by tissue hypoperfusion due to cardiac dysfunction, usually presenting with hypotension and signs of organ hypoperfusion. The Society for Cardiovascular Angiography and Interventions (SCAI) classifies CS into five stages from A (pre-shock) to E (extremis). This classification helps in understanding the severity and guiding management strategies.

Pathophysiology CS results from an imbalance between cardiac output and demand, leading to systemic hypoperfusion and organ dysfunction. Distinguishing between acute and acute-on-chronic CS is crucial, as mortality is higher in acute CS. Acute CS involves sudden ventricular contractility reduction, while acute-on-chronic CS involves a multisystem disorder evolving from chronic heart failure.

Epidemiology CS is less common than septic shock but poses significant clinical challenges. It accounts for 7-10% of ICU admissions, with a higher prevalence in cardiac ICUs. Data primarily come from registries of AMI-related CS, with limited data on non-AMI-CS.

Management of CS

1. Assessment and Diagnosis: A multimodal approach including clinical examination, echocardiography, and invasive hemodynamic assessment is crucial. Early TTE provides comprehensive cardiac information.
2. Monitoring: Early basic monitoring should be supplemented with advanced techniques in complicated cases. Lactate levels and echocardiography are essential for early recognition and classification.
3. Coronary Artery Revascularization: Emergent revascularization (PCI) is vital for AMI-CS patients. The CULPRIT-SHOCK trial supports a culprit-lesion-only strategy over multivessel PCI.
4. Arrhythmia Management: Immediate restoration of sinus rhythm is crucial for hemodynamic stability. Amiodarone is preferred for pharmacological cardioversion.
5. Valvular Disease Management: Cardiac surgery remains the gold standard, but percutaneous approaches are increasingly used.
6. Inotropes/Vasopressors: Early use of vasopressors and inotropes is recommended to maintain perfusion pressure. Norepinephrine is preferred over dopamine and epinephrine.
7. Mechanical Ventilation: Positive pressure ventilation (PPV) helps in respiratory management, improving gas exchange and reducing myocardial oxygen demand.
8. Renal Replacement Therapy (RRT): AKI is common in CS, and RRT is often required. Continuous RRT is preferred to avoid acute fluid shifts.
9. Acute Mechanical Circulatory Support (aMCS): aMCS should be considered for hemodynamic stabilization. Device selection depends on CS phenotype and local expertise.

Conclusions

Despite significant advances, CS remains a condition with high mortality. Early recognition and a multidisciplinary approach are crucial. Coronary revascularization is essential in AMI-CS, while other management strategies focus on restoring perfusion, supporting organ function, and considering mechanical support when necessary.

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Discussion Questions

1. How does the classification system by the Society for Cardiovascular Angiography and Interventions (SCAI) improve the management of cardiogenic shock, and what are its limitations?
2. What are the critical considerations in choosing between norepinephrine and other vasopressors or inotropes in the management of cardiogenic shock?
3. How does early mechanical circulatory support (aMCS) impact the outcomes in cardiogenic shock patients, and what are the current challenges in its implementation?

Javier Amador-Casta?eda, BHS, RRT, FCCM

Interprofessional Critical Care Network (ICCN)

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