CARDIOGENIC SHOCK Adrianus Kosasih

DEFINITION

a state of critical end-organ

hypoperfusion due to reduced
cardiac output.

Thiele H et al. European Heart Journal (2015) 36, 12231230

DIAGNOSIS CRITERIA
Systolic blood pressure <90 mmHg for >30 min or vasopressors
required to achieve a blood pressure 90 mmHg
Pulmonary congestion or elevated left-ventricular filling pressures
Signs of impaired organ perfusion with at least one of the following
criteria:
altered mental status;
cold, clammy skin;
oliguria;
increased serum-lactate

Thiele H et al. European Heart Journal (2015) 36, 12231230

DIAGNOSIS CRITERIA (ALT)
Persistent hypotension (systolic blood pressure <80 to 90
mm Hg or mean arterial pressure 30 mm Hg lower than
baseline)
Severe reduction in cardiac index (<1.8 L min1
m2 without support or <2.0 to 2.2 L min1 m2 with
support)
Adequate or elevated filling pressure (eg, left ventricular
[LV] end-diastolic pressure >18 mm Hg or right
ventricular [RV] end-diastolic pressure >10 to 15 mm
Hg)

Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697

EPIDEMIOLOGY

AMI is the leading cause of

cardiogenic shock (80%)
Complicating AMI in 5-15%
(STEMI in 5-8% cases, 2.5%
NSTEMI)
High mortality rate (80%
50%)

Thiele H et al. European Heart Journal (2015) 36, 12231230

Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697
ETIOLOGY
Acute coronary syndrome esp. STEMI and its complications
Arrhythmias
Cardiac tamponade
Myocarditis
Valvular disease
Metabolic and toxin
etc
Current concept of CS pathophysiology.

Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697

Copyright American Heart Association, Inc. All rights reserved.
Iatrogenic shock.

Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697

Copyright American Heart Association, Inc. All rights reserved.
DIAGNOSIS
Anamnesis and physical examination
ECG : STEMI (?), Ichemia (?)
Lab test: Blood count, blood gas analysis, cardiac enzyme, lactate,
BNP
Imaging : CXR, echocardiography, coronary angiography
TREATMENT

General treatment
Revascularization
Fluids, vasopressor, inotropes
Mechanical support
GENERAL TREATMENT
Antiplatelet: Aspirin with/out Thienopyridines/Ticagrelor
Avoid negative inotrope drugs (beta blockers)
Avoid vasodilator (nitrates)
Maintain normal/near normal arterial oxygenation and pH. Low
threshold for mechanical ventilation
Glycemic control. Insulin therapy when needed. Avoid hypoglycemia.
REVASCULARIZATION
Early revascularization is the most important treatment
strategy in CS complicating AMI.
PCI or CABG
Fibrinolytics is less effective, but indicated if PCI is
impossible or lengthy delay
INOTROPES - VASOPRESSORS
Norepinephrine
Dobutamine may be given simultaneously to norepinephrine in an
attempt to improve cardiac contractility
Note: catecholamines increase myocardial oxygen consumption and
vasoconstrictors may impair microcirculation as well as tissue
perfusion. Use should be restricted to the shortest possible duration
and the lowest possible dose.
Thiele H et al. European Heart Journal (2015) 36, 12231230
MECHANICAL SUPPORT

Intra-aortic balloon pump

Percutaneous Left Ventricular Assist Device
(LVAD)
Extracorporeal Life-Support System (ECLS)
IABP
IMPELLA
CONCLUSION
Cardiogenic shock has high mortality rate
The leading cause of cardiogenic shock is acute myocardial
infarction
Reperfusion therapy is the most important treatment
Avoid iatrogenic cardiogenic shock
Thank you