Current evidence in the diagnosis and management of cardiogenic shock complicating acute coronary syndrome

Abstract

Cardiogenic shock (CS) is a hemodynamically complex and highly morbid syndrome characterized by circulatory collapse and inadequate end-organ perfusion due to impaired cardiac output. It is usually associated with multiorgan failure and death. Mortality rate is still high despite advancement in treatment. CS has been conceptualised as a vicious cycle of injury and decompensation, both cardiac and systemic. Interrupting the vicious cycle and restoring the hemodynamic stability is a fundamental treatment of CS. Acute coronary syndrome (ACS) is the most frequent cause of CS. Early coronary revascularization is a cornerstone therapy that reduces mortality in patients with ACS complicated by CS. Early diagnosis of CS accompanied with invasive hemodynamics, helps in identification of CS phenotype, classification of CS severity, stratification of risk and prognostication. This can guide a tailored and optimized therapeutic approach. Inotropes and vasopressors are considered the firstline pharmacological option for hemodynamic instability. The current availability of the mechanical circulatory support devices has broadened the therapeutic choices for hemodynamic support. To date there is no pharmacological or nonpharmacological intervention for CS that showed a mortality benefit. The clinical practices in CS management remain inconsistent. Herein, this review discusses the current evidence in the diagnosis and management of CS complicating ACS, and features the changes in CS definition and classification.

The research progress and research trends in acute coronary syndrome nursing: A review of visual analysis based on the Web of Science database

“…[ 50 ] Some studies have summarized the management of cardiogenic shock complicated by ACS, which mainly includes early shock recognition, optimal selection and initiation of mechanical circulatory support, early coronary revascularization, shock team and implementation of standardized protocols, which play an important role in improving the outcome of cardiogenic shock in patients with ACS. [ 51 , 52 ] However, clinical practices for the management of cardiogenic shock are still inconsistent and knowledge gaps remain large, and it has become a future research trend to conduct systematic studies to explore the selection and timing of mechanical circulatory support and to standardize the medical care and management of patients with ACS complicated by cardiogenic shock.…”

Identification of distinct clinical phenotypes of cardiogenic shock using machine learning consensus clustering approach

“…The extracted variable included: [ 1 ] demographics: age, gender, ethnicity and body mass index (BMI); [ 2 ] ICU type: cardiac intensive care unit (CICU), cardiac surgery intensive care unit (CSICU), medical intensive care unit (MICU), surgery intensive care unit (SICU), cardiac care unit-cardiac trauma/surgical intensive care unit (CCU-CTICU), neuro intensive care unit (NICU), cardiac trauma intensive care unit (CTICU); [ 3 ] Medical history: myocardial infarction, coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), pacemaker, congestive heart failure, cardiac arrhythmias, hypertension, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), respiratory failure, stroke, neurologic disorders, diabetes, anemia, lymphoma, liver disease, peptic ulcer, metastatic cancer, rheumatoid arthritis, hypothyroidism, and acquired immunodeficiency syndrome (AIDS); [ 4 ] vital signs: systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), heart rate, respiratory rate, temperature, and oxygen saturation measured by pulse oximetry (SpO 2 ); [ 5 ] laboratory findings: white blood cell (WBC) count, red blood cell (RBC) count, platelet count, red blood cell distribution width (RDW), blood urea nitrogen (BUN), creatinine, estimated glomerular filtration rate (eGFR), glucose, total protein, albumin, bilirubin, total calcium, potassium, sodium, chloride, and bicarbonate; The eGFR was calculated using the modification of diet in renal disease (MDRD) formula [ 18 ]; [ 6 ] prognostic scoring system: systemic inflammatory response syndrome (SIRS) score, Sequential Organ Failure Assessment (SOFA) score, acute physiology score III (APS III) and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) sccore; [ 7 ] Treatment information: PCI, CABG, intraaortic balloon pump (IABP), mechanical ventilation, renal replacement treatment (RRT), and vasopressor use (dopamine, epinephrine, norepinephrine, or vasopressin). The definition of vasopressor use was at least one vasopressor was used during the first 24 h after admission.…”

“…Cardiogenic shock (CS), a state of circulatory failure, can occur due to acute ischaemic or non-ischaemic cardiac events, or from the progression of longstanding underlying heart disease [ 2 – 4 ]. Unfortunately, despite recent advances in pharmacological intervention or mechanical support, CS mortality remains unacceptably high and highly varied, with the 30-day mortality ranging from 50 to 90% [ 5 ]. The disparity in the mortality rates might imply CS patients are a heterogeneous population, and some phenotypes of CS are so different in clinical features and prognoses that they cannot be regarded as a whole population, both in clinical practice and research.…”

Revisiting nitrates use in pre-shock state of contemporary cardiogenic shock classification

“…As such, an improved SCAI stage by one category was a positive prognostic marker and vice versa ( 5 ). Pharmacological and non-pharmacological (i.e., mechanical) circulatory support are usually needed to combat hypotension and restore tissue hypoperfusion ( 8 ). In stage C there is hypoperfusion that usually requires vasoactive agents or mechanical circulatory support.…”