What is the workup for cardiogenic shock?

From the Guidelines

The workup for cardiogenic shock should begin with a rapid clinical assessment including vital signs, physical examination, and immediate diagnostic tests, prioritizing electrocardiogram (ECG), chest X-ray, and bedside echocardiography, as recommended by the most recent guidelines 1. The initial assessment should focus on identifying signs of hypoperfusion, such as oliguria, cold peripheries, altered mental status, lactate > 2 mmol/L, metabolic acidosis, and SvO2 < 65% 1. Key diagnostic tests include:

• Electrocardiogram (ECG) to identify acute myocardial infarction or arrhythmias
• Chest X-ray to evaluate for pulmonary edema or other cardiac abnormalities
• Laboratory tests, such as cardiac biomarkers (troponin, CK-MB), complete blood count, comprehensive metabolic panel, lactate, arterial blood gas, brain natriuretic peptide (BNP), and coagulation studies
• Bedside echocardiography to assess ventricular function, valvular abnormalities, and mechanical complications Hemodynamic monitoring via arterial line is recommended, and in complex cases, pulmonary artery catheterization may be necessary to measure cardiac output, pulmonary capillary wedge pressure, and calculate systemic vascular resistance 1. Coronary angiography should be performed urgently if acute coronary syndrome is suspected, and additional imaging such as CT angiography may be needed to rule out pulmonary embolism or aortic dissection 1. The workup should occur simultaneously with initial resuscitative measures, including oxygen therapy, careful fluid management, and potentially inotropic or vasopressor support, with a focus on rapid identification of the underlying cause of cardiogenic shock to improve outcomes 1.

From the Research

Cardiogenic Shock Workup

The workup for cardiogenic shock involves a structured approach to diagnose and manage the condition. The following steps are crucial in the workup:

• 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 2
• A structured ABCDE approach involving stabilization of the airway, breathing, and circulation, followed by damage control and etiologic assessment 2
• Echocardiography is essential to identify potential causes and characterize the phenotype of cardiogenic shock 2
• Coronary angiography is usually indicated, particularly when acute myocardial ischemia is suspected, followed by culprit-vessel revascularization if indicated 2
• An invasive hemodynamic assessment can clarify whether temporary mechanical circulatory support is necessary 2

Diagnostic Tests

The following diagnostic tests are used in the workup of cardiogenic shock:

• Electrocardiogram (ECG) to evaluate cardiac function 3
• Chest radiograph to evaluate lung function 3
• Laboratory studies to evaluate organ function and perfusion 3
• Bedside echocardiogram to evaluate cardiac function and identify potential causes of cardiogenic shock 3

Management

The management of cardiogenic shock involves the following:

• Early reperfusion strategies, such as percutaneous coronary intervention or coronary artery bypass grafting, are essential in the management of cardiogenic shock 4, 5
• Mechanical circulatory support is indicated for patients with cardiogenic shock who do not respond to pharmacologic therapy 3
• Mechanical ventilation is frequently needed in patients with cardiogenic shock, and the aim is to summarize and discuss the current evidence and the pathophysiological mechanism that a clinician should consider while setting the ventilator 6
• Positive pressure ventilation as part of first-line treatment in patients with cardiogenic failure may have a beneficial effect 6