Cardiogenic shock : Current evidence

Abstract

This CME article addresses the pathophysiology, incidence, current survival outcome and treatment options for patients with cardiogenic shock as a complication of acute myocardial infarction. The shock spiral of left heart failure due to cardiac infarction, subsequent vasoconstriction and paradoxical vasodilation due to the systemic inflammation response syndrome (SIRS) is a vicious circle which must be interrupted. Treatment focuses on the evidence from randomized clinical trials and the current guideline recommendations. With respect to interventional and surgical treatment the question of culprit lesion vs. complete revascularization is still unsolved. For medicinal treatment acetylsalicylic acid (ASA) and heparin are more often supplemented with prasugrel and ticagrelor. In the case of inotropes, dobutamine remains the first-line treatment option and for vasopressors norepinephrine. The calcium sensitizer levosimendan has not provided the hoped for superiority over conventional treatment in randomized trials. The use of intra-aortic balloon pumps (IABP) is no longer recommended as circulatory support in acute heart failure (reduced to classIII). The use of percutaneous implantable mechanical circulatory support devices has not shown asurvival benefit in the few randomized trials carried out so far even when compared with IABP, due to increased bleeding complications.