What are the causes of cardiogenic shock?

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Causes of Cardiogenic Shock

Acute myocardial infarction is the leading cause of cardiogenic shock, complicating 7-10% of AMI cases and typically requiring loss of at least 40% of left ventricular myocardium to precipitate shock. 1, 2

Primary Cardiac Causes

Acute Myocardial Infarction and Its Complications

AMI-related cardiogenic shock represents the most common etiology, with extensive myocardial necrosis or stunned but viable myocardium both contributing to post-AMI shock. 3, 1 The pathophysiology involves diminished cardiac output leading to systemic hypoperfusion and maladaptive cycles of ischemia, inflammation, vasoconstriction, and volume overload. 3

Mechanical complications of AMI are critical causes that require immediate recognition:

  • Left ventricular free wall rupture is the most serious complication following AMI with exceptionally high mortality. 1, 2
  • Ventricular septal rupture creates acute left-to-right shunting with rapid hemodynamic deterioration. 1, 2
  • Papillary muscle rupture leads to acute severe mitral regurgitation, which is a major predictor of mortality alongside LV ejection fraction. 1, 2
  • Right ventricular infarction most often associates with inferior AMI, manifesting with RV dyssynergy, dilatation, paradoxical septal motion, and decreased TAPSE. 2

Chronic Heart Failure Decompensation

Acute decompensated heart failure in patients with pre-existing cardiomyopathy can lead to cardiogenic shock, following a more indolent clinical course compared to AMI-related shock and more commonly requiring biventricular hemodynamic support. 3, 1, 2

Valvular Heart Disease

Severe valvular heart disease requiring emergency cardiac surgery can precipitate cardiogenic shock. 1, 2 Acute severe mitral regurgitation, either primary or secondary to LV dysfunction, represents a particularly important cause. 1

Inflammatory Cardiac Disease

Myocarditis causing acute myocardial inflammation and dysfunction can precipitate cardiogenic shock. 1, 2

Post-Cardiotomy Shock

Post-cardiotomy cardiogenic shock complicates 0.1% to 0.5% of cardiac surgeries, resulting from pre-existing myocardial dysfunction or intraoperative complications including inadequate myocardial protection, acute bypass graft failure, prosthetic valve dysfunction, pericardial effusion, or aortic dissection. 3

Arrhythmic Causes

Severe tachyarrhythmias or bradyarrhythmias causing hemodynamic compromise can precipitate cardiogenic shock. 1, 2 Atrial fibrillation is present in nearly 20% of cardiogenic shock patients. 1, 2

Conduction disorders associated with hemodynamic instability can cause cardiogenic shock. 1

Pathophysiologic Mechanisms

The central pathophysiologic derangement involves diminished cardiac output leading to systemic hypoperfusion. 3 This triggers maladaptive cycles where:

  • Impaired CO and progressive diastolic dysfunction raise ventricular end-diastolic pressures, reducing coronary perfusion pressure, myocardial contractility, and stroke volume. 3
  • Released inflammatory mediators further impair tissue metabolism and induce nitric oxide production, causing systemic vasodilation and exacerbating hypotension. 3
  • Hypoxia and pulmonary inflammation induce pulmonary vasoconstriction, increasing biventricular afterload and myocardial oxygen demand. 3
  • The renal response to impaired glomerular perfusion increases tubular sodium reabsorption and activation of the renin-angiotensin-aldosterone axis, resulting in further volume overload. 3
  • Sympathetically mediated splanchnic vasoconstriction redistributes 50% of total blood volume back to the circulation, worsening volume overload. 3

Critical Diagnostic Pitfall

Avoid confusing late-stage septic shock with cardiogenic shock—septic shock can develop myocardial depression, but the primary hemodynamic pattern remains distributive with decreased systemic vascular resistance, whereas cardiogenic shock demonstrates elevated SVR as a compensatory mechanism. 2 Invasive hemodynamic monitoring with pulmonary artery catheterization provides definitive measurements: cardiac index <2.2 L/min/m², PCWP >15 mmHg, CVP >15 mmHg, and elevated SVR. 2

References

1
Guideline

Cardiogenic Shock Causes and Characteristics

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Cardiogenic Shock Causes and Diagnosis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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