Advances in the Management of Cardiogenic Shock

Abstract

OBJECTIVES: To review a contemporary approach to the management of patients with cardiogenic shock (CS). DATA SOURCES: We reviewed salient medical literature regarding CS. STUDY SELECTION: We included professional society scientific statements and clinical studies examining outcomes in patients with CS, with a focus on randomized clinical trials. DATA EXTRACTION: We extracted salient study results and scientific statement recommendations regarding the management of CS. DATA SYNTHESIS: Professional society recommendations were integrated with evaluated studies. CONCLUSIONS: CS results in short-term mortality exceeding 30% despite standard therapy. While acute myocardial infarction (AMI) has been the focus of most CS research, heart failure-related CS now predominates at many centers. CS can present with a wide spectrum of shock severity, including patients who are normotensive despite ongoing hypoperfusion. The Society for Cardiovascular Angiography and Intervention Shock Classification categorizes patients with or at risk of CS according to shock severity, which predicts mortality. The CS population includes a heterogeneous mix of phenotypes defined by ventricular function, hemodynamic profile, biomarkers, and other clinical variables. Integrating the shock severity and CS phenotype with nonmodifiable risk factors for mortality can guide clinical decision-making and prognostication. Identifying and treating the cause of CS is crucial for success, including early culprit vessel revascularization for AMI. Vasopressors and inotropes titrated to restore arterial pressure and perfusion are the cornerstone of initial medical therapy for CS. Temporary mechanical circulatory support (MCS) is indicated for appropriately selected patients as a bridge to recovery, decision, durable MCS, or heart transplant. Randomized controlled trials have not demonstrated better survival with the routine use of temporary MCS in patients with CS. Accordingly, a multidisciplinary team-based approach should be used to tailor the type of hemodynamic support to each individual CS patient’s needs based on shock severity, phenotype, and exit strategy.

In‐hospital outcomes in unhoused patients with cardiogenic shock in the United States: Insights from The National Inpatient Sample 2011−2019

“…The optimal treatment of CS patients remains a subject of debate, however early revascularization for MI-driven CS, vasopressor/inotrope therapy, and temporary MCS with or without hemodynamic monitoring in select patients are tools in the armamentarium of clinicians tasked with treating this deadly condition. 27 Unhoused patients, when interviewed, endorse that stigmatization from health care professionals, tradeoffs between basic needs and medications, and situational instability are some of the unique challenges faced. 28 Concerns regarding long-term medication adherence limit the use of coronary revascularization in low SES and unhoused patients in the community.…”

A Case Report of Mycoplasma pneumoniae-induced fulminant myocarditis in a 15-year-old male leading to cardiogenic shock and electrical storm

“…Due to inadequate efficacy of pharmacological interventions, mechanical circulatory support was necessary to ensure systemic and coronary perfusion, facilitate venous drainage, and prevent multiple organ dysfunction ( 16 ). The timely application of IABP immediately following the initial episode of VF was chosen for its convenience and cost-effectiveness.…”

Application of Cardiovascular Physiology to the Critically Ill Patient

“…of arterial resistance and venous capacitance vessels as well as TBV; the presence of structural heart disease; and degree of right heart dysfunction (80,81).…”