What is the management of cardiogenic shock?

Management of Cardiogenic Shock

The management of cardiogenic shock requires a rapid, structured multidisciplinary approach focused on immediate evaluation, hemodynamic stabilization, correction of the underlying cause, and mechanical circulatory support when necessary, ideally in a tertiary center with 24/7 cardiac catheterization capabilities. 1

Definition and Recognition

Cardiogenic shock is defined as:

• Hypotension (SBP <90 mmHg) despite adequate filling status
• Signs of hypoperfusion
• Hemodynamic criteria: cardiac index <2.2 L/min/m², pulmonary capillary wedge pressure >15 mmHg 2

Initial Assessment and Monitoring

• Immediate Doppler echocardiography to assess ventricular and valvular functions, loading conditions, and detect mechanical complications 2
• Invasive blood pressure monitoring with an arterial line 2
• Consider placement of a pulmonary artery line to define hemodynamic subsets and guide management strategies 2
• Monitor: cardiac index, mixed venous oxygen saturation, mean arterial pressure, urine output, and lactate clearance 1

Pharmacological Management

First-line Therapy

• Intravenous inotropic support should be used to maintain systemic perfusion and preserve end-organ function 2
• Dobutamine (2-20 μg/kg/min) is the most commonly used inotropic agent to increase cardiac output 1
• Norepinephrine is the first-line vasopressor when arterial pressure support is needed 1, 3

Second-line Options

• For persistent hypotension, consider adding dopamine 5-15 μg/kg/min IV 1
• Levosimendan may be considered in combination with vasopressors or as an alternative 1
• Phosphodiesterase-3 inhibitors (milrinone) may be considered, especially in non-ischemic patients 1

Caution: Excessive vasopressors may increase myocardial oxygen demand and worsen ischemia 1

Respiratory Support

• Oxygen/mechanical respiratory support according to blood gases 2
• For respiratory distress (respiratory rate >25 breaths/min, SaO2 <90%), consider non-invasive positive pressure ventilation 2
• Endotracheal intubation and ventilatory support may be required in patients unable to achieve adequate oxygenation 2

Revascularization and Mechanical Support

Revascularization

• Immediate PCI is indicated for patients with cardiogenic shock if coronary anatomy is suitable 2
• If coronary anatomy is not suitable for PCI, or PCI has failed, emergency CABG is recommended 2
• Complete revascularization during the index procedure should be considered 2

Mechanical Circulatory Support (MCS)

• Temporary MCS is reasonable when end-organ function cannot be maintained by pharmacologic means 2
• Consider transfer to centers with MCS capabilities if not rapidly responding to initial measures 2
• Routine use of intra-aortic balloon pump is not recommended based on the IABP-SHOCK II trial 1

Team-Based Approach

• Management by a multidisciplinary team experienced in shock is reasonable 2
• Team should include HF specialists, critical care specialists, interventional cardiologists, and cardiac surgeons 1
• For patients not rapidly responding to initial shock measures, triage to centers that can provide temporary MCS 2

Special Considerations for Older Adults

• Older adults may present with atypical or delayed presentations, requiring a high index of suspicion 2
• Age has been strongly associated with mortality among mechanically ventilated patients 2
• Patient wishes regarding mechanical ventilation should be considered before initiation of invasive ventilation 2

Monitoring Response to Therapy

Target parameters:

• Cardiac index ≥2.2 L/min/m²
• Mixed venous oxygen saturation ≥70%
• Mean arterial pressure ≥70 mmHg
• Urine output >30 mL/h
• Lactate clearance 1

The management of cardiogenic shock is complex and requires rapid intervention. Despite advances in treatment, mortality remains high (50-80%), highlighting the importance of early recognition and aggressive management within a specialized care setting 1.