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URRENT
C
OPINION
Purpose of review
The natural history of cardiogenic shock has improved significantly with the utilization of revascularization
and mechanical circulatory support. Despite the interest in identifying new pharmacological agents, the
medical therapy to restore perfusion is limited by their side-effects and no solid evidence about improving
outcomes. In this article, we review the current pharmacological agents utilized during cardiogenic shock.
Recent findings
Inotropes and vasopressors are widely used to improve hemodynamics acutely; however, reliable
information regarding comparative efficacy of individual agents is lacking. A subanalysis of a prospective
randomized trial suggested that norepinephrine may be preferred over dopamine in patients with
cardiogenic shock. Levosimendan is a new inotrope with calcium sensitization properties that improves
acute hemodynamics, but with uncertain effects in mortality. Diuretics are used to decongest patients;
however, mortality data are not available. Inhibition of inflammation during cardiogenic shock seems to be
a potential therapeutic target; however, initial clinical studies in this area have not shown benefit.
Summary
The current pharmacological treatment for cardiogenic shock includes inotropes, vasopressors and
diuretics. The information about comparative effective outcomes is limited and their use should be limited as
a temporary measure as a bridge to recovery, mechanical circulatory support or heart transplantation.
Keywords
inotropes, shock, vasopressors
INTRODUCTION
Cardiogenic shock is a stage of heart failure characterized by decreased tissue perfusion from cardiac
pump failure. Clinically, cardiogenic shock presents
with an evidence of congestion (dyspnea, orthopnea, high jugular venous pressure, rales, edema,
ascites) and low perfusion (hypotension, narrow
pulse pressure, pulsus alternans, cool forearms and
legs, obtunded mental status, oliguria), a clinical
scenario commonly described as a wet and cold
patient [1]. Hemodynamically, cardiogenic shock is
defined as persistent hypotension (systolic blood
pressure <8090 mmHg or mean arterial pressure
30 mmHg lower than baseline) with severe
reduction in cardiac index (<1.8 l/min/m2 without
support or <2.02.2 l/min/m2 with support) and
adequate or elevated filling pressures (e.g., left ventricular end-diastolic pressure >18 mmHg or right
ventricular end-diastolic pressure >1015 mmHg)
[2 ]. Hemodynamic definition of cardiogenic shock
is as follows:
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a
Division of Cardiovascular Medicine, Department of Medicine, University
of Utah School of Medicine, bCardiology Section, Veterans Affairs Salt
Lake City Healthcare System and cDivision of Cardiothoracic Surgery,
Department of Surgery, University of Utah School of Medicine, Salt Lake
City, Utah, USA
KEY POINTS
Medical therapies for cardiogenic shock include
inotropes, vasopressors and diuretics.
There is limited information about comparative efficacy
among pharmacological agents.
The utilization of inotropes, vasopressors and diuretics
is limited by their adverse event profile and limited
improvement in outcomes.
The utilization of inotropes and vasopressors is
recommended as a temporary measure as a bridge to
recovery, mechanical circulatory support or heart
transplantation.
Dobutamine
(b) <2.02.2 l/min/m2 with support (support
indicates use of vasoactive drugs or mechanical circulatory support)
(3) Adequate or elevated filling pressures
(a) Left ventricular end-diastolic pressure
>18 mmHg or
(b) Right ventricular end-diastolic pressure
>1015 mmHg (Adapted from [2 ])
&&
Location
Response to activation
b1
Heart
&&
Increase AV nodal
conduction velocity
b2
Smooth muscle
(vascular, bronchial,
GI and GU)
Relaxation
a1
Contraction
Heart
Increase force of
contraction
a2
Contraction
D1
Vascular smooth
muscle (renal)
Relaxation
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Cardiac failure
Table 2. Inotropes and vasopressors for cardiogenic shock
Medication
Mechanism/receptor
Therapeutic dose
BP
HR
CO
SVR
Dobutamine
b1 > b2 > a
215 mg/kg/min
"
""
Milrinone
PDE-3 inhibitor
0.3750.75 mg/kg/min
##
"
""
##
Levosimendan
Calcium sensitizer
0.050.2 mg/kg/min
""
##
Epinephrine
b1 b2 > a
"
"
"""
Norepinephrine
b1 > a > b2
""
0 or #
""
Dopamine
Moderate dose b
25 mg/kg/min
""
"
""
0 or #
Dopamine
High dose a
515 mg/kg/min
""
""
"
""
Phenylephrine
a1
4060 mg/min
""
"
Vasopressin
V1
0.010.04 units/min
""
""
BP, blood pressure; CO, cardiac output; HR, heart rate; PDE, phosphodiesterase; SVR, systemic vascular resistance.
scenarios, including intermittent [6] and continuous intravenous (i.v.) infusions [7]. The recommended dose is from 2 to 15 mg/kg/min [8] and
does not require renal adjustment.
Milrinone
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Calcium sensitizers
30
10
LVDP
(mm/Hg)
Heart rate
(beats/min)
00
00
90
80
70
40
30
20
60
90
20
800
1400
1000
600
20
0 2 5 8 11 14 RC 125 25 50 75
Dobutamine
mcg/kg/min
40
Milrinone
mcg/kg
0 2 5 8 11 14 RC125 25 50 75
Dobutamine
mcg/kg/min
Milrinone
mcg/kg
FIGURE 1. Hemodynamic effects of dobutamine vs. milrinone in heart failure. The effects of dobutamine and milrinone are
dose-dependent. Compared with dobutamine, milrinone produces lower mean arterial pressure, lower systemic vascular
resistance, lower left ventricular end diastolic pressure and lower peak positive dP/dt. dP/dt, index of left ventricle pressure
rise in early systole; LVDP, left ventricular diastolic pressure.
or blood pressure. There was a small and nonsignificant decrease in the pulmonary capillary wedge
pressure and pulmonary vascular resistance. Six of
the 10 patients died, four from refractory cardiogenic shock, one from intracerebral bleed and one
from mesenteric embolization.
The role of levosimendan in cardiogenic shock
remains unclear. The recommended dose is 0.05
0.2 mg/kg/min, but levosimendan is not recommended in systolic blood pressures <90 mmHg [19].
Epinephrine
Epinephrine (adrenaline) is a strong agonist of a and
b receptors. Its use results in the elevation of
systemic blood pressure through positive inotropic
effect, positive chronotropic effect and vasoconstriction in the cutaneous and renal vascular beds.
Epinephrine increases stroke volume and cardiac
output and decreases SVR by stimulating b2
Norepinephrine
Norepinephrine differs from epinephrine only in
the methyl substitution in the amino group. It is
a potent a agonist, and also stimulates b1 receptors.
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Cardiac failure
Dopamine
Dopamine is an endogenous catecholamine with
cardiovascular effects that are dose-dependent. At
low doses (2 mg/kg), it causes vasodilation by stimulating dopaminergic receptors on smooth muscle
and by stimulating D2 receptors, which are dominant in splanchnic and renal artery beds. At intermediate doses (25 mg/kg/min), it stimulates b
receptors in the heart and on vascular sympathetic
neurons. At higher doses (515 mg/kg/min), alpha
adrenergic stimulation occurs, with peripheral arterial and venous constriction [20]. The effects of
dopamine in cardiogenic shock include an elevation
in the heart rate (11%), cardiac output (40%),
stroke volume (30%) and left ventricular end diastolic pressures (2.4 mm Hg), with a reduction in
SVR (20%) [20]. In animal models, high doses of
dopamine increase mean pulmonary artery pressures without changes in pulmonary vascular resistance [23].
The effects of dopamine and norepinephrine in
the treatment of shock of different causes were
recently examined in a randomized trial. Patients
assigned to dopamine and norepinephrine had
similar mortality during intensive care (50 vs.
46%, P 0.07), during overall hospital stay (59 vs.
57%, P 0.24) and at 12 months (66 vs. 63%,
P 0.34). Patients assigned to dopamine had higher
rate of arrhythmias compared with patients on
norepinephrine, including atrial fibrillation (20.5
vs. 11%, P 0.001), ventricular tachycardia (2.4
vs. 1.0%, P <0.001) and ventricular fibrillation
(1.2 vs. 0.5%, P <0.001). A subgroup analysis in
patients with cardiogenic shock demonstrated that
patients treated with dopamine had a higher 28-day
mortality rate compared with norepinephrine
[22 ]. The reasons for this finding are unclear,
but could be related to higher heart rate with dopamine or to pharmacological differences between the
two drugs, with norepinephrine causing higher
elevations in SVR compared with dopamine. The
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Phenylephrine
Phenylephrine differs little from epinephrine in
chemical structure but is an a1 selective agonist
[20]. It increases peripheral vascular resistance and
blood pressure. The elevation in blood pressure
stimulates baroreceptors with activation of the vagal
reflex with significant bradycardia. Because of the
decreased heart rate, the cardiac output also
decreases, but to a lower degree compared with
the heart rate, secondary to an increase in venous
return and stroke volume [25]. Because of its negative effect on the cardiac output, utilization in cardiogenic shock is rare and it is more frequently
utilized for vasodilatory shock. The recommended
dose is 4060 mg/min.
Vasopressin
Vasopressin in high doses activates vascular smooth
muscle V1 and oxytocin receptors, causing vasoconstriction [26]. Vasopressin is most commonly
used in vasodilatory septic shock, in which it has
been best studied [2731]. In patients with refractory cardiogenic shock complicating myocardial
infarction, a retrospective analysis of 36 patients
showed that vasopressin increased the mean arterial
pressure from 56 to 73 mmHg without affecting
pulmonary capillary wedge pressure, cardiac index
or the urine output [32]. Vasopressin is considered
to be a reasonable vasopressor choice for cardiogenic
shock from right ventricular failure as experimental
data have shown that it does not increase pulmonary vascular resistance [33]. Vasopressin also
effectively reverses hypotension when vasoplegia
complicates left ventricular assist device and transplant surgery due to a relative vasopressin-deficient
state [34,35]. A combination of milrinone and
vasopressin can be considered to counteract the
systemic vasodilatory effects of milrinone. The
recommended dose is 0.010.04 units/min.
Loop diuretics
Furosemide is a loop diuretic that blocks the
sodium-potassium-chloride transporter, and therefore increases urinary excretion of Na and Cl.
Furosemide also acutely increases the systemic
venous capacitance, decreasing left ventricular
filling pressures independently of its diuretic effect
[3840]. The oral bioavailability of furosemide can
be markedly reduced during congestion, making
the i.v. route preferred in cardiogenic shock. The
response to furosemide is decreased when underlying renal function is abnormal. There are no
clinical trials of diuretics in cardiogenic shock, but
the Diuretic Strategies in Patients with Acute
Decompensated Heart Failure trial evaluated the
outcomes of high (2.5 outpatient oral dose) vs.
low dose (outpatient oral dose) and intermittent vs.
continuous infusion of furosemide in patients
with decompensated heart failure. After 72 h, there
were no differences in the co-primary end-point of
global assessment of symptoms and change in
serum creatinine level when diuretics were administered by bolus compared with continuous infusion
or at high dose compared with a low dose. However,
the higher dose group compared with the low dose
group was associated with greater weight loss
(8.7 vs. 6.1 pounds, P 0.011), and greater net
volume loss at 72 h (4.8 vs. 3.6 l, P 0.001) but with
a transient increase in serum creatinine (23 vs. 14%,
P 0.041) [41]. Bumetanide and torsemide are other
commonly used loop diuretics.
ANTI-INFLAMMATORY AGENTS
SVR is typically elevated in cardiogenic shock. However, some patients present with profound hypotension and normal or decreased SVR. The proposed
mechanisms for this vasoplegic state include activation of KATP channels in the vascular smooth
muscle, vasopressin deficiency and the release of
cytokines and nitric oxide due to an underlying
inflammatory process [44,45]. Inflammatory modulators have been identified as potential targets for
therapy.
Tilarginine
Nitric oxide is a proinflammatory mediator
that stimulates guanylate cyclase, increasing
cyclic guanosine monophosphatase (cGMP) and
smooth muscle relaxation. It has been shown
that nitric oxide synthase (NOS) is upregulated
in acute myocardial infarction [46,47]. As the
vasodilatory effect of NOS can contribute to hypotension in shock, NOS inhibition has been proposed as a therapeutic target. In the Tilarginine
Acetate Injection in a Randomized International
Study in Unstable Acute Myocardial Infarction
Patients with Cardiogenic Shock trial, 398 patients
with acute coronary syndrome, percutaneous
revascularization and cardiogenic shock refractory
to vasopressor therapy were randomized to NOS
inhibitor tilarginine (1 mg/kg bolus 1 mg/kg/h
5-h infusion) vs. placebo. Enrolment was terminated early, however, after an interim analysis
showed no differences between the treatment
groups in 30-day and 6-month mortality, shock
duration and resolution [48].
Methylene blue
Methylene blue is a guanylate cyclase inhibitor that
decreases cGMP and circumvents its vasodilatory
effects in the smooth muscle [49]. In patients with
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Cardiac failure
CONCLUSION
There has been limited progress in pharmacological
approaches in the treatment of cardiogenic shock.
Vasoactive medications inotropes and vasopressors are widely used to acutely improve hemodynamics; however, reliable information regarding
comparative efficacy of individual agents is lacking.
A common clinical practice in the setting of cardiogenic shock is to initiate therapy with inotropes and
to add, or transition to, vasopressors, if hypotension
persists. Nevertheless, this approach has not been
tested in prospective trials. A subanalysis of a lone
prospective randomized trial suggested that norepinephrine may be preferred over dopamine in
patients with cardiogenic shock [22 ]. Diuretics
are used to decongest patients in cardiogenic shock
and volume overload; however, mortality data are
also not available for this group of medications.
Inhibition of inflammation during cardiogenic
shock seems to be a potential therapeutic target;
however, initial clinical studies in this area have
not shown benefit.
In summary, vasoactive therapies have predictable favorable acute effect on hemodynamics in
most patients; however, their use is accompanied
by significant adverse events and possibly increased
mortality. Other strategies, including early introduction of mechanical circulatory support, may
improve survival in cardiogenic shock, and this
hypothesis should be tested in clinical trials. In
the meantime, the use of vasoactive agents should
be limited to the dose and time necessary to restore
tissue perfusion before recovery of myocardial function takes place (where this can be accomplished), or
before advanced therapies, including mechanical
circulatory support or heart transplantation, can
be implemented.
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Acknowledgements
None.
Conflicts of interest
There are no conflicts of interest.
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