Managing the first 120 min of cardiogenic shock: from resuscitation to diagnosis

Abstract

Purpose of reviewCardiogenic shock continues to carry a high mortality, and recent randomized trials have not identified novel therapies that improve survival. Early optimization of patients with confirmed or suspected cardiogenic shock is crucial, as patients can quickly transition from a hemodynamic shock state to a treatment-resistant hemometabolic shock state, where accumulated metabolic derangements trigger a selfperpetuating cycle of worsening shock. Recent findingsWe describe a structured ABCDE approach involving stabilization of the airway, breathing and circulation, followed by damage control and etiologic assessment. Respiratory failure is common and many cardiogenic shock patients require invasive mechanical ventilation. Norepinephrine is titrated to restore mean arterial pressure and dobutamine is titrated to restore cardiac output and organ perfusion.Echocardiography is essential to identify potential causes and characterize the phenotype of cardiogenic shock. Coronary angiography is usually indicated, particularly when acute myocardial ischemia is suspected, followed by culprit-vessel revascularization if indicated. An invasive hemodynamic assessment can clarify whether temporary mechanical circulatory support is necessary. SummaryEarly stabilization of hemodynamics and end-organ function is necessary to achieve best outcomes in cardiogenic shock. Using a structured approach tailored to initial cardiogenic shock resuscitation may help to demonstrate benefit from novel therapies in the future.

Association Between the Acidemia, Lactic Acidosis, and Shock Severity With Outcomes in Patients With Cardiogenic Shock

“…These metabolic derangements contribute to a worsening shock state termed hemometabolic shock . 8 , 17 , 18 , 19 Breaking this shock‐acidosis‐shock vicious cycle using alkali therapy (such as sodium bicarbonate) to reverse systemic acidemia seems logical, but this approach remains controversial and has not been clearly demonstrated to improve outcomes in critically ill patients. 29 , 31 Greater benefits of alkali may be observed in patients with acute kidney injury, and we anticipate that patients with CS with lower blood pH might more likely to benefit.…”

“…A therapeutic trial of alkali therapy can be considered for patients with CS with severe systemic acidemia from metabolic acidosis if they are not responding appropriately to standard doses of vasopressors, but future studies are need to determine the benefit of this approach. 18 , 30 …”

“… 5 , 6 , 8 During CS, tissue hypoperfusion and organ failure lead to metabolic deficiencies and a treatment‐resistant hemometabolic CS phenotype. 5 , 8 , 17 , 18 , 19 Simple blood biomarkers can capture this, as lactic acidosis (defined as an elevated blood lactate level) is a well‐established predictor of mortality in patients with CS. 8 , 20 , 21 , 22 , 23 , 24 , 25 Likewise, systemic acidemia (defined as a low blood pH) predicts mortality in patients with CS and may quantify the severity of the hemometabolic disturbance.…”

Advances in the Management of Cardiogenic Shock

“…Early recognition with identification and treatment of the underlying cause is a central goal in the initial management of patients with CS ( Supplemental Table 1 , http://links.lww.com/CCM/H343) (1, 2, 6, 38, 39). An electrocardiogram and point-of-care cardiac ultrasound are useful to screen for myocardial ischemia, left ventricle (LV)/RV dysfunction, and structural heart disease (38, 39).…”

“…Noninvasive ventilation with continuous positive airway pressure can reduce work of breathing and improve pulmonary edema; high-flow nasal cannula may be useful, particularly when positive airway pressure is not desirable (44). When invasive mechanical ventilation is needed, lung-protective ventilation limiting the tidal volume and driving pressure may be considered in the absence of supporting evidence (1, 38, 44). While positive pressure ventilation may improve LV loading conditions and ameliorate pulmonary edema, it is essential to recognize the potential for positive pressure ventilation to potentially worsen hemodynamics depending on volume status and RV function (44).…”