CARDIOGENIC SHOCK

CARDIOGENIC SHOCK

• Definition
• Etiology
• Pathophysiology
• Clinical features
• Monitoring
• Positive şi etiological diagnosis
• Differential diagnosis
• Principles of treatment
 DEFINITION

= clinical syndrome caused by an acute disturbance of heart

function, which induces the reduction of systemic blood
pressure and tissue hypoperfusion with consecutive
dysfunction of diverse systems and organs.

= systemic BP< 90mmHg or mean BP< cu 30mmHg

compared with basic values
IC < 2,2l/min m2
PCPB > 15mmHg
 ETIOLOGY
• Decreased myocardial contractility
- Myocardial infarction
- Cardiomiopathy
- Drugs, metabolic disturbances, post-extracorporeal circulation
• Ventricular outflow obstruction
- Aortic stenosis
- Hypertrofic subvalvular aortic stenosis
• Ventricular filling anomalies
• mitral stenosis
• atrial myxoma
• Valvular disfunction
• Acute mitral regurgitation
• Acute tricuspid regurgitation
• Cardiac disrhytmias
• Tachyarrhytmias
• Bradyarrhytmias
• Cardiac ruppture
• Myocardial infarction
• Cardiac trauma
 PATHOPHYSIOLOGY
myocardial ischemia ± necrosis → LV, RV, both
↓
• Systolic myocardial dysfunction→ ↓ contractility → ↓ cardiac
output→ ↓ Cardiac Index → ↓ systemic BP
• Diastolic myocardial dysfunction → ↓ LV compliance→
↑ LVTDP → ↑ retrograde pressure → ↑ PCPB → pulmonary congestion→
hypoxemia
• Neuro-vegetative response→↑sympatic stimulation +↑ cortisol, ADH
+ ↑ SRAA → peripheral vasoconstriction → oliguria + metabolic acidosis

compensatory mechanisms evolve to decompensated phenomena

vicious circles = death spiral
PATHOPHYSIOLOGY
 CLINICAL SIGNS
• Arterial hypotension
• Signs of tissue hypoperfusion
• Signs of pulmonary congestion

• altered mental status

• Cyanosis, cold extremities, profuse sweting
• Hypotension, low pulse amplitude
• Tachypnea, dyspnea,pulmonary rales , turgescent jugular veins
• Tachycardia, arrhytmias (brady-/tachyarrhytmias),heart murmurs or
overlapping heart sounds
• Oliguria
 MONITORING
• Clinical signs: mental status, temperature and the colour of the skin
• SpO2
• invasive BP
• ECG
• CVP
• hemodynamic parameters: pulmonary artery pressure, PCPB,
RVS, RVP
DC, SvO2
• Echocardiography
• Urinary output
• pH + blood gas analysis
• Functions of different systems and organs: renal, liver,
glycemia, coagulation tests , electrolytes, Hb, Ht, WBC count
MONITORING
MONITORING
MONITORING
MONITORING
MONITORING
MONITORING
 MONITORING
• Clinical signs: mental status, temperature and the colour of the skin
• SpO2
• invasive BP
• ECG
• CVP
• hemodynamic parameters: pulmonary artery pressure, PCPB,
RVS, RVP
DC, SvO2
• Echocardiography
• Urinary output
• pH + blood gas analysis
• Function of different systems and organs: renal, liver,
glycemia, coagulation tests , electrolytes, Hb, Ht, WBC count
 DIAGNOSIS

• positive diagnosis clinical signs

hemodynamic parametres

• ethiological diagnosis ECG

Hemodynamic parameters
Myocardial enzymes
Echocardiography
others investigations
 DIFFERENTIAL DIAGNOSIS
• With other forms of shock

FC TA DC PVC PCPB RVP Da-vO2 SvO2

Hypovolemic ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓
shock

Cardiogenic ↑ ↓↓ ↓ ↑ ↑ ↑ ↑ ↓
shock

septic shock ↑ ↓ ↑N ↓N N ↓ ↓ ↑
 PRINCIPLES OF TREATMENT
• early and aggresive treatment –

save time
• Save functional myocardium

improvement of the myocardial oxygen supply/demand

balance
• Save ischemic myocardium

Myocardial reperfusion
 PRINCIPLES OF TREATMENT
• Improvement of the myocardial oxygen supply
-demand relationship
• ↑ myocardial oxygen supply
• Hypoxemia correction – O2 therapy, ventilator support (CPAP, PEEP)
• Hypotension correction – volemic therapy
vasoconstrictors
• Improvement of cardiac output - inotropic agents
↓ myocardial oxygen demand
• Treatment of pain – opioid analgesics
• Treatment of cardiac dysrhytmias – cardioversion
antiarrhytmic agents
pacing

• Other possibilities of hemodynamic support

• Intraaortic ballon counterpulsation
• Mechanical ventricular assist devices
PRINCIPLES OF TREATMENT
 PRINCIPLES OF TREATMENT

• myocardial reperfusion
– Thrombolysis
– PTCA
– Cardiac surgery: emergency coronary artery by-pass
correction of mechanical defects
cardiac transplant
 CONCLUSIONS

• Cardiogenic shock is most frequently, the consequence of

acute myocardial infarction
• Mortality is high (40-80%)
• The clinical picture is a sum of signs of tissular
hypoperfusion, signs of pulmonary hypotension and
hypotension
• Invasive hemodynamic monitoring is essential for diagnosis
and guiding of treatment
• Early initialization of general treatment, and myocardial
reperfusion – improve the chances of survival
• Early PTCA - the treatment of choice.