What is the recommended acute management of a patient with ischemic heart disease presenting in cardiogenic shock?

Management of Ischemic Heart Disease with Cardiogenic Shock

Immediate PCI is the definitive treatment for patients with ischemic heart disease presenting in cardiogenic shock, and should be performed emergently regardless of time from symptom onset to improve survival. 1

Immediate Revascularization Strategy

Emergency coronary revascularization is the only treatment proven to decrease mortality in cardiogenic shock complicating acute myocardial infarction. 1

• Perform immediate PCI of the culprit vessel if coronary anatomy is suitable 1
• If coronary anatomy is not suitable for PCI or PCI has failed, proceed directly to emergency CABG 1
• In STEMI patients with cardiogenic shock where PCI would be delayed >120 minutes, administer immediate fibrinolysis and transfer to a PCI center 1
• Upon arrival at the PCI center after fibrinolysis, perform emergent angiography regardless of ST resolution or time from fibrinolysis 1
• Complete revascularization during the index procedure should be considered in patients presenting with cardiogenic shock 1
• Do NOT perform routine PCI of noninfarct-related arteries at the time of primary PCI—this increases risk of death and renal failure 1

Hemodynamic Monitoring and Assessment

Establish invasive arterial blood pressure monitoring immediately for accurate hemodynamic assessment. 1, 2

• Perform immediate Doppler echocardiography to assess ventricular and valvular function, loading conditions, and detect mechanical complications (acute mitral regurgitation, ventricular septal rupture, free wall rupture) 1, 2
• Hemodynamic assessment with pulmonary artery catheter may be considered for confirming diagnosis or guiding therapy 1, 2
• Cardiogenic shock is defined as persistent hypotension (SBP <90 mmHg) despite adequate filling status with signs of hypoperfusion: oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis, or SvO2 <65% 1, 2

Initial Hemodynamic Support

Volume Management

• In patients with hypotension and normal perfusion WITHOUT evidence of congestion or volume overload, attempt gentle volume loading (fluid challenge with saline or Ringer's lactate >200 mL over 15-30 minutes) after ruling out mechanical complications 1, 2
• In patients with RV infarction, avoid volume overload as it might worsen hemodynamics 1, 2

Inotropic and Vasopressor Therapy

• Dobutamine is the preferred first-line inotropic agent to increase cardiac output when signs of low cardiac output persist 1, 2, 3
• Start dobutamine at 2.5-5 μg/kg/min and titrate up to 10-20 μg/kg/min based on hemodynamic response 2, 3
• Levosimendan may be considered, especially in chronic heart failure patients on oral beta-blockade 1
• Norepinephrine is the preferred vasopressor over dopamine if vasopressor support is needed to maintain systolic BP in the presence of persistent hypoperfusion 1, 2
• Vasopressors should only be used if there is a strict need to maintain systolic BP in the presence of persistent hypoperfusion 1

Respiratory Support

• Provide oxygen/mechanical respiratory support according to blood gases to maintain oxygen saturation >90% 1, 2
• Endotracheal intubation and mechanical ventilation with positive end-expiratory pressure is usually necessary in patients with respiratory failure 1

Mechanical Circulatory Support

The evidence for mechanical circulatory support devices in cardiogenic shock is evolving, with specific indications for different devices.

Intra-Aortic Balloon Pump (IABP)

• Routine intra-aortic balloon pumping is NOT indicated in cardiogenic shock 1, 2
• IABP should be considered specifically in patients with hemodynamic instability/cardiogenic shock due to mechanical complications (ventricular septal rupture, acute mitral regurgitation) 1, 2

Advanced Mechanical Circulatory Support

• In selected patients with STEMI and severe or refractory cardiogenic shock, insertion of a microaxial intravascular flow pump (Impella) is reasonable to reduce death 1
• Short-term mechanical circulatory support may be considered in patients with refractory shock depending on patient age, comorbidities, and neurological function 1, 2
• In patients with mechanical complications of ACS, short-term MCS devices are reasonable for hemodynamic stabilization as a bridge to surgery 1
• Routine use of VA-ECMO is NOT recommended due to lack of survival benefit 1

Additional Critical Interventions

Pharmacological Therapies

• Administer standard pharmacological therapies including aspirin, P2Y12 receptor antagonist (ticagrelor or prasugrel preferred over clopidogrel), and anticoagulation 1
• IV GP IIb/IIIa inhibitors have shown benefit in observational studies 1

Arrhythmia Management

• Place temporary pacemaker for patients with bradycardia or high-degree atrioventricular heart block 1
• Correct or control tachyarrhythmias 1

Mechanical Complications

• Mechanical complications must be treated as early as possible after discussion by the Heart Team 1, 2

Transfer and Team-Based Care

• All patients with cardiogenic shock should be rapidly transferred to a tertiary care center with 24/7 cardiac catheterization capability and dedicated ICU with availability of short-term mechanical circulatory support 1, 2
• Implement a multidisciplinary shock team approach—team-based cardiogenic shock management has been associated with improved 30-day all-cause mortality 2
• Patients presenting to hospitals without PCI capability should be emergently transported to a PCI center, as mortality without transfer is markedly elevated 1

Critical Pitfalls to Avoid

• Do NOT delay revascularization—cardiogenic shock has in-hospital mortality rates of 40-50% despite advances in treatment 1, 2, 4
• Do NOT routinely use IABP—it has not shown mortality benefit in randomized trials 1, 2
• Do NOT perform multivessel PCI at the time of primary PCI in cardiogenic shock—treat culprit vessel only 1
• Revascularization attempts may be futile and not indicated in cases of severe multiorgan failure 1
• Avoid negative inotropes and vasodilators historically 1