From the Guidelines
Cardiogenic shock is a life-threatening condition characterized by hypotension, inadequate tissue perfusion, and signs of end-organ hypoperfusion, requiring immediate medical attention to reduce morbidity, mortality, and improve quality of life. The symptoms of cardiogenic shock include hypotension (systolic blood pressure below 90 mmHg), tachycardia, cool and clammy skin, decreased urine output, altered mental status ranging from confusion to unconsciousness, and respiratory distress with rapid breathing 1. Other common symptoms include chest pain, especially in cases triggered by myocardial infarction, weak or rapid pulse, fatigue, dizziness, and peripheral cyanosis (bluish discoloration of extremities) 1. Patients may also exhibit pulmonary edema symptoms like coughing up pink, frothy sputum.
Key Symptoms and Signs
- Hypotension (systolic blood pressure below 90 mmHg)
- Tachycardia
- Cool and clammy skin
- Decreased urine output
- Altered mental status
- Respiratory distress with rapid breathing
- Chest pain
- Weak or rapid pulse
- Fatigue
- Dizziness
- Peripheral cyanosis
Diagnosis and Management
The diagnosis of cardiogenic shock is based on the presence of hypotension and signs of end-organ hypoperfusion, such as oliguria, cold peripheries, altered mental status, lactate > 2 mmol/L, metabolic acidosis, and SvO2 < 65% 1. Immediate assessment, including ECG and echocardiography, is required in all patients with suspected cardiogenic shock 1. Invasive monitoring with an arterial line and consideration of pulmonary artery catheterization may also be necessary 1.
Treatment
The treatment of cardiogenic shock should focus on improving organ perfusion by increasing cardiac output and blood pressure, using a combination of fluid challenge, inotropic agents, and vasopressors as needed. Norepinephrine is recommended as the first-line vasopressor, and dobutamine or levosimendan may be used as inotropic agents 1. Mechanical circulatory support, such as intra-aortic balloon pump or percutaneous left ventricular assist device, may be considered in patients who do not respond to medical therapy 1.
Prioritization of Outcomes
In the management of cardiogenic shock, the prioritization of outcomes should focus on reducing morbidity, mortality, and improving quality of life. This can be achieved by promptly recognizing the symptoms of cardiogenic shock, initiating immediate medical attention, and using evidence-based treatments to improve organ perfusion and cardiac function.
From the Research
Cardiogenic Shock Symptoms
- Cardiogenic shock is a primary cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion and can lead to multi-organ failure and death depending on its severity 2
- It is characterized by reduced cardiac output secondary to systolic dysfunction which can lead to multi-organ failure 3
- The classic form of cardiogenic shock requires administration of inotropic and/or vasopressor agents to try to improve the impaired tissue perfusion 4
Causes of Cardiogenic Shock
- Inadequate cardiac contractility or cardiac power secondary to acute myocardial infarction remains the most frequent cause of cardiogenic shock 2
- Although its contribution has declined over the past two decades, compared with other causes 2
Management of Cardiogenic Shock
- The management of cardiogenic shock is based on immediate stabilization of haemodynamic parameters so that further treatment, including mechanical circulatory support and transfer to specialized tertiary care centres, can be accomplished 2
- Medical therapy, consisting mainly of inotropic drugs and vasopressors, still has a major role in the management of cardiogenic shock 2, 4, 3, 5
- Norepinephrine is recommended as first-line vasopressor agent by various guidelines 4, 3, 5
- Dobutamine is the first-line inotrope agent whereas levosimendan can be used as a second-line agent or preferentially in patients previously treated with beta-blockers 4, 3, 5