Cardiogenic shock

icu perspective
2015 french consensus

1. Dr imran gafoor Consultant intensivism Mar,2018 ICU perspective CARDIOGENIC SHOCK

2. Definition :it’s critical end organ hypoperfusion d/t ↓ CO Or, it’s an acute heart failure secondary to MI with mortality > 50% In it cardiac filling pressures are ↑ but CO ↓ Note shock is compromised end organ perfusion (not necessitating ↓ SBP) Tenets of therapy include restore CO & treat causative factors ( hypoxia,arrthymia,hypervolemia,coronary ischemia,acidosis,mechanical MI complications) Purpose of therapy is prevention of MOF & irreversible organ damage Leading cause of death in CS cohort is MOF

3. Established criteria for diagnosis :

4. Weakness,fatigue,ashen dyspnea,cough,othopnea,PND tachycardia,pul rales,S3S4 gallop,MR murmur ( lt heart) pain,↑ JVP,hepatomegaly,ascites,peripheral edema ( rt heart)

5. ↑ JVP > S3 gallop signifies increased risk of hospitilisation & death

6. In CS,a coronary cause should be routinely sought (70% cases d/t STEMI) Predictors of progression to CS within 2 days of MI : age,diabetes ,>75bpm on arrival,H /O MI,CABG,ant infarction, signs of HF + Coronary angio f/b revascularisation using angio (stent)/CABG is required in pump failure after MI ( usually within 18 hrs of onset of shock or till 2days without shock ) Monitoring : A line (mandatory) C line (for ScVO2) lactate (in absence of epi therapy) routine ECG,transthorasic ECHO cardiac markers PAC/TTD/pulse contour analysis for refractory shock with predominant rt V dysfunction

7. Pressors : norepi + dobutamine (epi may be alternative) In case of LVOT obstruction or hypertrophic cardiomyopathy with severe DD PHENYLEPHERINE is vasoactive agent Avoid dopamine Levosimendan /milrinone are not first line agents but can be used as second line after cardiac sx In proven post cardiac arrest cardiogenic shock,especially in shockable rhythms.routine coronary angio is recommended IABP should not be used,if cardiogenic shock managed effectively by angioplasty (IABP-SHOCK II trial) In reversible cardiogenic shock,bridge to transplant – IABP,impella , VA-ECMO Attempt pacemakers in LBBB with wide QRS Should receive heparin,aspirin,clopidogrel,A fib t/t Avoid nitrates,β blockers,ACEI in acute phase Ischemic CS Hb target 10,in non ischemic 8

8. For CS with severe AS :valvuloplasty as early as possible For CS with MR : sx within 12 hrs Levosimendan can be used as first line after CABG Milrinone can be used as first line in CS with rt V failure Β blocker,Ca channel blocker,LA toxicity – VA ECMO + medical m/m (Provided hypokinesis established thru ECHO) Low dose β blockers,ACEI,aldosterone antagonists started after shock reversal Bromocriptine can be considered in post partum cardiomyopathy provided chronic heart /genetic condition ruled out

9. Decrease BP after intubation/MV/mild sedative doses usually signify hypovolemia Even cardiogenic shock may benefit from judicious amount of fluids as edema ↓ effective intravascular volume Fluid challenge is 300-500 ml crystalloids in 20-30 mins with targets of ↑ BP,↓ HR or ↑ UO It is acceptable to provide vasopressors while fluid challenge/resuscitation is underway Hyotension after starting dobutamine may suggest hypovolemia If ScVO2 ≤ 70% → add dobutamine Target lactate clearance rate of atleast 20% over 2 hrs CLINICAL SNIPPETS…..

10. CS can complicate both STEMI/NSTEMI when it usually involves ant wall of myocardium CS due to chronic Heart conditions are characterized by ↑ SVR while acute insults have ↓ SVR Lowest effective dose of inotropes should be used Pace of therapeutic intervention in nay shock is decided by clinical assessment of end organ hypoperfusion CLINICAL SNIPPETS…..

11. Questions & Discussion