cardiogenic shock case study

Overall, 40,000 to 50,000 cases of cardiogenic shock occur annually in the United States. © Patient Platform Limited. Francis GS, Bartos JA, Adatya S; Inotropes. Provide symptom relief if needed - eg, opiate analgesia. Options for temporary support devices have expanded beyond the intraaortic balloon pump (IABP) and ECMO to include percutaneously placed continuous-flow support devices and surgically placed paracorporeal pumps (discussed in detail later in this chapter). How should cardiogenic shock be managed (including assist devices)? Cardiogenic shock occurs in about 4% of patients following STEMI.12 Risk factors for cardiogenic shock include extensive infarction, anterior infarction, previous myocardial infarction, low ejection fraction, and multivessel coronary artery disease. By continuing you agree to the use of cookies. CXR: can show tension pneumothorax, widened mediastinum in aortic dissection, signs of left ventricular failure. 1 in the chapter Anatomy of the Heart and Circulation). Hochman JS, Sleeper LA, Webb JG, et al; Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. BMJ. 13 23-1). 1 Define cardiogenic shock. Mortality rates are variable but may be as high as 50%. The complete occlusion of a coronary artery by a clot causes death of an area of heart muscle that is supplied by that blood vessel and its branches. Cardiogenic shock should be strongly considered when there is no history of fluid losses, the physical examination reveals hepatomegaly or rales, the chest radiograph demonstrates cardiomegaly, and there is no clinical improvement despite oxygenation and volume expansion. JAMA. In the case of combination therapy, patients can be weaned off Western medicine treatment. They are written by UK doctors and based on research evidence, UK and European Guidelines. Revascularisation with thrombolysis, percutaneous intervention or coronary artery bypass surgery should be considered. Consider pharmacological inotropic support (see directly below). eCollection 2015. They may allow survival to cardiac transplantation. There is currently no strong evidence to support a distinct inotropic or vasodilator drug-based therapy as best treatment to reduce mortality in haemodynamically unstable patients with cardiogenic shock or low cardiac output complicating acute MI. Patients with right ventricular failure may have distended neck veins with visible pulsations (V waves; see Figure 8-11) that are indicative of tricuspid regurgitation. Gilani FS, Farooqui S, Doddamani R, et al; Percutaneous Mechanical Support in Cardiogenic Shock: A Review. 2013 Mar84(3):319-25. doi: 10.1016/j.resuscitation.2012.09.034. Circulatory shock is characterized by the inability of tissue blood flow and oxygen delivery to meet metabolic demands. Intravenous fluids: 250 ml boluses should be used if any co-existent depletion of intravascular volume is present. inotropic: [ in″o-trop´ik ] affecting the force of muscular contractions. In general, anterior wall and large distribution infarcts carry a higher risk of cardiogenic shock but some patients may manifest shock with smaller infarcts in the setting of pre‐existing left ventricular dysfunction. Become a COVID-19 treatment pioneer today. Hypotension (remember to check BP in both arms in case of aortic dissection). Most patients who develop cardiogenic shock do so within 24 hours of the myocardial infarction. 2006 Apr81(4):1365-70. The George Washington University, Washington, D.C., United States, Pontificia Universidad Católica de Chile, Santiago, Chile, Institut für Herzinfarktforschung, Ludwigshafen, Germany, Beaumont Hospital-Royal Oak, Royal Oak, United States, Before the emphasis on time-to-treatment and primary PCI, the incidence of, Integrative Cardiovascular Chinese Medicine, Acute myocardial infarction is the most common cause of, Comprehensive Pediatric Hospital Medicine. Ital Heart J. Acute Management of Myocardial Infarction with ST-Segment Elevation, Casella G, Savonitto S, Chiarella F, et al, Unverzagt S, Wachsmuth L, Hirsch K, et al, Gilani FS, Farooqui S, Doddamani R, et al, Leshnower BG, Gleason TG, O'Hara ML, et al, Schmidt-Schweda S, Ohler A, Post H, et al. Unlike what is commonly believed, cardiogenic shock may also occur in up to 2% to 3% of patients with non–ST-segment-elevation myocardial infarction (NSTEMI). Cardiogenic shock is defined as decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume (see Chapter 23). Blood is held up in the lungs and fluid accumulates in air sacs causing pulmonary edema which results in severe shortness of breath. Because dead myocardium cannot contract, blood cannot be effectively ejected out of the left ventricle into the aorta [see Fig. Results from the latter trial and others led to the development of CS teams across the United States. NICE has issued rapid update guidelines in relation to many of these. Haemodynamic monitoring using a Swan-Ganz catheter can help to differentiate cardiogenic shock from other causes of shock such as hypovolaemia. Acute myocardial infarction is the most common cause of cardiogenic shock. At least 25% of patients who subsequently develop cardiogenic shock will have had a cardiac arrest, usually at presentation.11 Following cardiac arrest, patients may suffer hypoxic ischemic encephalopathy (HIE; see Chapter 37). Perform an ECG early: this can show acute MI. Non-invasive positive pressure ventilation (NIPPV) may be helpful in mild-to-moderate cases of cardiogenic shock (provided the BP can support it). As early as possible during treatment, encourage the patient to organize diet and lifestyle modifications to address all disease conditions which contribute to cardiovascular disease. The skin, brain, heart and kidneys are usually most severely affected by this. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. The most common cause of shock in children is sepsis, followed by hypovolemic shock, distributive shock and, finally, cardiogenic shock. Bilateral basal pulmonary crackles or wheeze may occur. M. GABRIEL KHAN MD, FRCP[C], FRCP[LONDON], FACP, FACC, in Encyclopedia of Heart Diseases, 2006. Biochemical abnormalities include hyperglycemia, lactic acidosis, increased blood urea nitrogen and creatinine, and elevations in hepatic transaminases. Geographically isolated patients may be unwilling or unable to travel for specialty care. In an analysis of 287 consecutive CS patients with acute coronary syndromes enrolled into the national cVAD registry, early initiation of Impella (Abiomed Inc., Danvers, MA) TCS before escalation of inotropes was associated with improved survival.21 In the cohort, overall survival to discharge was 44%. JAMA. U&Es and creatinine can assess renal function. Patient does not provide medical advice, diagnosis or treatment. doi: 10.1002/14651858.CD009669.pub2. In general, excluding patients with congenital heart disease, cardiogenic shock is much less common inchildren than in adults because of the relatively low incidence of coronary artery disease and congestive heart failure in the pediatric population. Myocardial diastolic function also is impaired in patients with cardiogenic shock. Epub 2014 Feb 12. Papillary muscle dysfunction caused by ischemia is common and can lead to substantial increases in left atrial pressure; the degree of mitral regurgitation may be lessened by afterload reduction. Evaluation through a history and physical examination can often yield a diagnosis and be confirmed through echocardiography. Shock is due to an inability to perfuse vital organs and tissues adequately. Cardiac rupture (rupture of the wall of the left ventricle can occur post-MI or due to cardiac trauma). doi: 10.1002/14651858.CD007398.pub3. Ventricular septal rupture (usually occurring as post-MI complication). While various definitions are used in the literature, evidences of persistent hypotension (systolic blood pressure < 80–90 mm Hg or a mean arterial pressure 30 mm Hg below baseline) with a low cardiac index (< 1.8 L/min/m2 without support or < 2.0–2.2 L/min/m2 with support), reduced cardiac power output (< 0.6 W), and elevated filling pressures (left ventricular end-diastolic pressure > 18 mm Hg or right atrial pressure > 10–15 mm Hg), along with cool extremities, lactic acidosis, and/or evidence of end-organ dysfunction, are signs of CS.4,9 CS presents on a wide continuum, and patient phenotypes can vary based on underlying cardiac etiology and the presence or absence of preexisting systolic dysfunction (Fig. 2006 Jun 7295(21):2511-5. In fact, despite the decline in its incidence with progressive use of timely primary PCI, cardiogenic shock still occurs in 5% to 8% of hospitalized patients with ST-segment-elevation myocardial infarction (STEMI). Percutaneous revascularisation was associated with a reduced risk of death. Ann Thorac Surg. I was recently sorting through some old Hospital paperwork and came across a letter dated February 2019 about a result I had from a CT scan of my chest, at the time I had a bad cough and breathing... Assess your symptoms online with our free symptom checker. Ducas J, Grech ED; ABC of interventional cardiology. Sustained hypotension (systolic blood pressure (BP) <90 mm Hg for more than 30 minutes). J Am Coll Cardiol. What could be causing your pins and needles? 2003 Jun 28326(7404):1450-2. Treat any underlying causes - eg, usual management of acute MI, urgent valve repair. Other causes of cardiogenic shock are given in Table 1. Andrew M. Fine, in Comprehensive Pediatric Hospital Medicine, 2007. Is it safe to delay your period for your holiday? Upgrade to Patient Pro Medical Professional? Gain venous access; patients often require central venous access as peripherally shut down - send bloods (see 'Investigations', below). Myocardial suppression due to bacteraemia or sepsis (although, strictly speaking, this may be defined as septic shock). 2015 Mar 273:CD007398. Singh M, White J, Hasdai D, et al; Long-term outcome and its predictors among patients with ST-segment elevation myocardial infarction complicated by shock: insights from the GUSTO-I trial. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. From: Critical Care Medicine (Third Edition), 2008, Hani Jneid, in Cardiology Secrets (Fifth Edition), 2018. Shock that occurs beyond 24 hours should raise the possibility of a mechanical complication of myocardial infarction, such as papillary muscle rupture, ventricular septal rupture, or ventricular free wall rupture. It occurs in 7% of patients with ST-segment elevation MI and 3% with non ST-segment elevation MI. This can guide the need for fluid resuscitation. Cardiogenic shock occurs when there is failure of the pump action of the heart, resulting in a decrease in cardiac output causing reduced end-organ perfusion. Patients who received TCS within 1.3 hours of CS presentation had a 66% survival to discharge, compared with 37% and 26% in those who received TCS at 1.3–4.3 and > 4.3 hours after CS presentation, respectively.21 The frequency of survival was also inversely proportional to the number of inotropes required prior to the initiation of MCS. 2015 May 289(Suppl 2):23-8. doi: 10.4137/CMC.S19707. It is more likely to develop in the elderly and in those with diabetes. Early coronary revascularisation in patients post-MI and adequate treatment of patients with structural heart disease may help to prevent cardiogenic shock. Hypovolemic shock is a medical emergency and an advanced form of hypovolemia due to insufficient amounts of blood and/or fluid inside the human body to let the heart pump enough blood to the body. Post-cardiac surgery requiring prolonged cardioplegia and cardiopulmonary bypass. Although cardiogenic shock is uncommon as the primary cause of shock in children, it may be a late manifestation of other forms of shock. COVID-19: how to treat coronavirus at home. IABP counterpulsation increases cardiac output and improves coronary artery blood flow. Coronavirus: what are moderate, severe and critical COVID-19? Hypertrophic obstructive cardiomyopathy or end-stage cardiomyopathy of other cause. Fox KA, Steg PG, Eagle KA, et al; Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006. Leshnower BG, Gleason TG, O'Hara ML, et al; Safety and efficacy of left ventricular assist device support in postmyocardial infarction cardiogenic shock. Cochrane Database Syst Rev. Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. 2014 May 2763(20):2069-78. doi: 10.1016/j.jacc.2014.01.016. JACC: Case Reports Editor-in-Chief Dr. Julia Grapsa, MD, PhD. The failure to define cardiogenic shock consistently or to confirm hemodynamically the presence of an elevated pulmonary capillary wedge pressure and low cardiac index have previously confused the clinician and confounded the literature. Suppression of myocardial contractility by drugs (eg, beta-blockers) or due to metabolic disturbance (eg, acidosis, hypokalaemia or hyperkalaemia, hypocalcaemia). The clinical impact of CS and advanced heart failure has spurred the growth of the Advanced Heart Failure surgical and medical specialties and the development of institutional CS protocols dedicated to rapid patient resuscitation. The most common cause of cardiogenic shock is acute MI.20 Often, anterior MI from acute thrombotic occlusion of the left anterior descending artery results in extensive infarction. Cardiogenic shock can also occur for reasons unrelated to myocardial infarction, such as pericardial tamponade, fulminant myocarditis, or acute valvular dysfunction. Cardiogenic shock is the leading cause of death after acute myocardial infarction and is an important cause of multiple organ dysfunction syndrome (MODS). (Arterial line, simple central venous line for CVP monitoring and a PiCCO® line are alternatives to a Swan-Ganz catheter.). BP monitoring (usually via an arterial line). Acute Management of Myocardial Infarction with ST-Segment Elevation; Editors National Clinical Guideline Centre (UK), 2013. Insertion of a Swan-Ganz catheter (not performed routinely): allows monitoring of CVP and pulmonary capillary wedge pressure. Cardiac arrest, typically ventricular fibrillation, occurs in about 3% of patients with STEMI12 and may be the presenting feature. Vasopressor/inotropic medications used include dopamine, dobutamine, enoximone, and milrinone. We use cookies to help provide and enhance our service and tailor content and ads. 2014 Sep-Oct46(4):301-6. doi: 10.5603/AIT.2014.0049. Percutaneous coronary intervention: cardiogenic shock. Ventricular assist devices: these are essentially prosthetic ventricles that can support right and left ventricle performance. As many patients with cardiogenic shock have had an acute MI, symptoms can include: See separate Acute Myocardial Infarction Management article. For details see our conditions. Try our Symptom Checker Got any other symptoms? In general patients with cardiogenic shock manifest persistent hypotension (systolic blood pressure less than 80 to 90 mm Hg or a mean arterial pressure 30 mm Hg below baseline), with a severe reduction in cardiac index (less than 1.8 L/min per m2) in the presence of adequate or elevated filling pressure (left ventricular [LV] end-diastolic pressure above 18 mm Hg or right ventricular (RV) end-diastolic pressure above 10 to 15 mm Hg). CT pulmonary angiography (CTPA) or ventilation/perfusion lung scan (also known as V/Q scanning) to look for PE may be appropriate but only once the patient is stabilised (D-dimer is likely to be raised so less useful). Matthew R. Biery, Benjamin Kohl, in Evidence-Based Practice of Critical Care (Third Edition), 2020. : Cardiogenic shock (CS) refers to the inability to deliver oxygen effectively due to cardiac dysfunction. The latter group is more likely to have circumflex artery occlusion, comorbid disease, and severe three-vessel disease or left main disease.28 Cardiogenic shock usually develops early after onset of symptoms, with approximately half of patients developing shock within 6 hours and 72% developing shock within 24 hours.29 Others first develop a preshock state manifested by systemic hypoperfusion without hypotension.30 These patients benefit from aggressive supportive therapy, and revascularization; early intervention may abort the onset of cardiogenic shock. 5.2). Jennifer Cowger, Daniel J. Goldstein, in Mechanical Circulatory Support: a Companion to Braunwald's Heart Disease (Second Edition), 2020, CS is best identified using both hemodynamic criteria and clinical signs/symptoms. Oliguria (catheterisation is a useful early monitoring intervention). Tissue hypoperfusion (cold peripheries, or. Hani Jneid, in Cardiology Secrets (Fifth Edition), 2018. Registered number: 10004395 Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. Short-Term Efficacy and Safety of Different Mechanical Hemodynamic Support Devices for Cardiogenic Shock or High-Risk Pci: a Network Meta-Analysis of Thirty-Seven Trials Duan, Jingwei; Shi, … Patient is a UK registered trade mark. 2007 May 2297(17):1892-900. Moderate hypothermia may improve parameters of cardiac function. Cardiogenic shock can be defined as the presence of the following (despite adequate left ventricular filling pressure): Cardiogenic shock most commonly occurs as a complication of acute myocardial infarction (MI). Myocardial contusion (often from steering wheel impact). The overall case fatality rate in this study was 2.3%. First-line investigations can help to determine the underlying cause of cardiogenic shock. Patient aims to help the world proactively manage its healthcare, supplying evidence-based information on a wide range of medical and health topics to patients and health professionals. [1]This leads to acute hypoperfusion and hypoxia of the tissues and organs, despite the presence of an adequate intravascular volume. Our clinical information is certified to meet NHS England's Information Standard.Read more. Pale, mottled, cold skin with slow capillary refill and poor peripheral pulses. This mechanism is distinct from complete rupture of the papillary muscle, a mechanical complication that manifests dramatically, with pulmonary edema and cardiogenic shock. Coronavirus: how quickly do COVID-19 symptoms develop and how long do they last? A recent study showed that, among patients with cardiogenic shock who survive for 30 days after an ST-segment elevation myocardial infarction (MI), annual mortality rates of 2% to 4% are approximately the same as those of patients without shock. You may find one of our health articles more useful. Low cardiac output (<2 L/min/m2) not related to hypovolemia (i.e., pulmonary artery wedge pressure <12 mm Hg), arrhythmia, hypoxemia, acidosis, or atrioventricular block. Echocardiography: this can establish the cause of cardiogenic shock - eg, acute ventricular septal defect, pericardial tamponade. Epub 2012 Oct 5. The diagnosis of cardiogenic shock should include the following: Systolic blood pressure less than 80 mm Hg without inotropic or vasopressor support, or less than 90 mm Hg with inotropic or vasopressor support, for at least 30 minutes. The main causes are listed in Box 37-2. from the best health experts in the business. Cardiogenic shock occurs when there is decreased cardiac output caused by pump failure. Tung RH, Garcia C, Morss AM, et al; Utility of B-type natriuretic peptide for the evaluation of intensive care unit shock. [] This leads to acute hypoperfusion and hypoxia of the tissues and organs, despite the presence of an adequate intravascular volume. Tissue hypoperfusion manifested by oliguria (<30 mL/hr), peripheral vasoconstriction, or altered mental status. Heaves, thrills or murmurs may be present and may indicate the cause, such as valve dysfunction. What happens to your body when you come off the pill? ECG may be normal in other causes of cardiogenic shock. Editorial board members from JACC: Case Reports, JACC: Cardiovascular Imaging, and JACC: Cardiovascular Interventions host a joint Virtual Journal Club discussing research on valvular heart disease and structural interventions. Although inotropes increase cardiac output, they may also increase mortality due to increased tachycardia and myocardial oxygen consumption leading to arrhythmia and myocardial ischaemia. All rights reserved. Treatment of CS is accomplished through a multidisciplinary approach and a combination of medical therapies, medical devices, and revascularization. Szymanski FM, Filipiak KJ; Cardiogenic shock - diagnostic and therapeutic options in the light of new scientific data. The papillary muscle of the mitral valve may infarct or rupture, causing acute, severe mitral regurgitation.22 Rupture of the interventricular septum causing ventricular septal defect23 or rupture of the left ventricular free wall producing pericardial tamponade24 also needs to be considered. With newer training in bedside ultrasound, this can now be performed with accuracy by the critical care physician. This guidance is changing frequently. Pericardial tamponade or severe constrictive pericarditis. Casella G, Savonitto S, Chiarella F, et al; Clinical characteristics and outcome of diabetic patients with acute myocardial infarction. Percutaneous mechanical support can provide substantial haemodynamic improvement in refractory cardiogenic shock. Resuscitation. Registered in England and Wales. The patient’s condition can be stabilized while introducing Chinese medicine decoctions for preparing for patient discharge back to regular life. Because blood cannot be ejected from the heart, the blood pressure falls drastically. The information on this page is written and peer reviewed by qualified clinicians. 2005 May6(5):374-83. Clin Med Insights Cardiol. 2007 Oct 3050(18):1752-8. When more than 40% of the heart muscle is involved, cardiogenic shock often occurs. Professional Reference articles are designed for health professionals to use. Elevation of left ventricular pressures can lead to pulmonary edema and hypoxemia (see Fig. Intubation and mechanical ventilation may be needed; provide oxygen as adequate. Diagnosis can be difficult because CS may coexist in the presence of other forms of shock. The delayed onset of shock may result from reocclusion of a patent infarct artery, infarct extension, or metabolic decompensation of non–infarct zone regional wall motion. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below. Although evidence suggests that IABP may have a beneficial effect on some haemodynamic parameters, there is no strong evidence of survival benefits to support the use of IABP in infarct-related cardiogenic shock. Clinical signs of tissue hypoperfusion include cool clammy skin, peripheral cyanosis, oliguria, tachycardia, confusion, and drowsiness. More specifically, hypovolemic shock occurs when there is decreased intravascular volume to the point of cardiovascular compromise. History of previous infarction, peripheral vascular disease, cerebrovascular disease and multi-vessel atheroma increases the likelihood of the development of cardiogenic shock. While survivors had similar hemodynamics prior to the initiation of mechanical circulation support (MCS), survivors of CS were more likely to have received TCS prior to percutaneous intervention and had shorter times from the onset of CS to TCS initiation. Acute mitral regurgitation (usually as a complication of MI due to ruptured chordae tendinae). Eric R. Bates, in Cardiac Intensive Care (Second Edition), 2010. Hani Jneid M.D., in Cardiology Secrets (Third Edition), 2010. The workload of the heart can be minimized by the achievement of normothermia, correction of anemia if present, and sedation, intubation, and mechanical ventilation if necessary. Potentially correctable underlying causes such as tension pneumothorax, massive PE, occult haemorrhage or hypovolaemia, sepsis, pericardial tamponade, anaphylaxis or respiratory failure should be kept in mind while assessment is carried out. Cochrane Database Syst Rev. Mechanical complications unrelated to infarct size account for approximately 12% of cases. Lockdown easing: what is the plan and is it realistic? Other causes of cardiogenic shock that are not emphasized in this chapter include end-stage cardiomyopathy, myocardial contusion, myocarditis, hypertrophic cardiomyopathy, valvular heart disease, pericardial disease, and post–cardiopulmonary bypass. Another cause of shock following myocardial infarction is right ventricular failure. Commonly, fatalities in cardiogenic shock range between 50% and higher based on constitution and age. Data from the BLITZ-1 study. The aim of management is to make the diagnosis, prevent further ischaemia and treat the underlying cause. Cardiogenic shock is a state of end-organ hypoperfusion due to cardiac failure and the inability of the cardiovascular system to provide adequate blood flow to the extremities and vital organs. Acute MI remains the leading cause of cardiogenic shock in the United States. Of pediatric patients who present to the emergency department in shock, sepsis is the leading cause (57%), followed by hypovolemic shock (24%), distributive shock (14%), and cardiogenic shock (5%).