Cardiogenic shock

Cardiogenic shock is based upon an inadequate circulation of blood due to primary failure of the ventricles of the heart to function effectively.^{[1][2][3][4] [5]}

Since this is a category of shock there is insufficient perfusion of tissue (i.e. the heart) to meet the required demand for oxygen and nutrients. This leads to cell death from oxygen starvation (hypoxia) and nutrient starvation (eg hypoglycemia).^[6][7] Because of this it may lead to cardiac arrest (or circulatory arrest) which is an acute cessation of cardiac pump function.^[4]

Cardiogenic shock is defined by sustained hypotension with tissue hypoperfusion despite adequate left ventricular filling pressure. Signs of tissue hypoperfusion include oliguria (<30 mL/h), cool extremities, and altered level of consciousness.

Etiology

Cardiogenic shock is caused by the failure of the heart to pump effectively. It can be due to damage to the heart muscle, most often from a large myocardial infarction. Other causes include arrhythmia, cardiomyopathy, cardiac valve problems, ventricular outflow obstruction (i.e. aortic valve stenosis, aortic dissection, systolic anterior motion (SAM) in hypertrophic cardiomyopathy), ventriculoseptal defects or medical error.^{[1][2][4][3][5][8][9]}

Signs and symptoms

• Anxiety, restlessness, altered mental state due to decreased cerebral perfusion and subsequent hypoxia.
• Hypotension due to decrease in cardiac output.
• A rapid, weak, thready pulse due to decreased circulation combined with tachycardia.
• Cool, clammy, and mottled skin (cutis marmorata), due to vasoconstriction and subsequent hypoperfusion of the skin.
• Distended jugular veins due to increased jugular venous pressure.
• Oliguria (low urine output) due to insufficient renal perfusion if condition persists.
• Rapid and deep respirations (hyperventilation) due to sympathetic nervous system stimulation and acidosis.
• Fatigue due to hyperventilation and hypoxia.
• Absent pulse in tachyarrhythmia.
• Pulmonary edema, involving fluid back-up in the lungs due to insufficient pumping of the heart..

Diagnosis

Electrocardiogram

An electrocardiogram helps establishing the exact diagnosis and guides treatment, it may reveal:

• Cardiac arrhythmias
• Signs of cardiomyopathy

Radiology

Echocardiography may show poor ventricular function, signs of PED, ventricular septal rupture (VSR), an obstructed outflow tract or cardiomyopathy.

Swan-ganz catheter

The Swan-ganz catheter or Pulmonary artery catheter may assist in the diagnosis by providing information on the hemodynamics.

Biopsy

In case of suspected cardiomyopathy a biopsy of heart muscle may be needed to make a definite diagnosis. but biopsy should only be done when third space is suspected

Treatment

In cardiogenic shock: depending on the type of myocardal infarction one can infuse fluids or in shock refractory to infusing fluids inotropica. In case of cardiac arrhythmia several anti-arrhythmic agents may be administered, i.e. adenosine, verapamil, amiodarone, β-blocker or glucagon.^[10] Positive inotropic agents, which enhance the heart's pumping capabilities, are used to improve the contractility and correct the hypotension. Should that not suffice an intra-aortic balloon pump (which reduces workload for the heart, and improves perfusion of the coronary arteries) can be considered or a left ventricular assist device (which augments the pump-function of the heart).^[1][2][3]

Cardiogenic shock may be treated with intravenous dobutamine, which acts on β₁ receptors of the heart leading to increased contractility and heart rate. ^[11]

References

External links

• Cardiogenic Shock by eMedicine