Definition Of Cardiogenic Shock Research Articles

What is cardiogenic shock? New clinical criteria urgently needed.

Cardiogenic shock is a clinical syndrome with different causes and a complex pathophysiology. Recent evidence from clinical trials evokes the urgent need for redefining clinical diagnostic criteria to be compliant with the definition of cardiogenic shock and current diagnostic methods. Conflicting results from randomized clinical trials investigating mechanical circulatory support in patients with cardiogenic shock have elicited several extremely important questions. At minimum, it is questionable whether survivors of cardiac arrest should be included in trials focused on cardiogenic shock. Moreover, considering the wide availability of ultrasound and hemodynamic monitors capable of arterial pressure analysis, the current clinical diagnostic criteria based on the presence of hypotension and hypoperfusion have become insufficient. As such, new clinical criteria for the diagnosis of cardiogenic shock should include evidence of low cardiac output and appropriate ventricular filling pressure. Clinical diagnostic criteria for cardiogenic shock should be revised to better define cardiac pump failure as a primary cause of hemodynamic compromise.

Pharmaceutical therapy of infarct-related cardiogenic shock

Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a comparably seldom but fatal entity. The definition of cardiogenic shock - unlike e. g. septic shock - is not uniform. Immediate revascularization is central to the patient's prognosis in AMI-CS. Patients who continue to meet the criteria of shock despite revascularization should be hemodynamically phenotyped to allow guidance of personalized subsequent therapy. Antiplatelet medication is the cornerstone for maintaining myocardial (re)perfusion. In hypotension, norepinephrine should be used as the first-line vasopressor, depending on afterload and after compensation for possible hypovolemia. Dobutamine is recommended to increase inotropy, possibly augmented or substituted by calcium sensitizers such as levosimendan. PDE-III (phosphodiesterase enzyme type III)-inhibitors should be used with restraint in myocardial infarction. Dopamine is no longer recommended in Europe. A sasodilator may be an option in highly selected patients with AMI-CS. This review will provide a detailed updated overview on pharmacological treatment modalities and indications in individual patients.

Abstract 10466: Randomized Clinical Trials Assessing Patients with Acute Myocardial Infarction-Related Cardiogenic Shock - A Systematic Review of Used Cardiogenic Shock Definitions and Outcomes

Introduction: Cardiogenic shock (CS) is a critical complication to acute myocardial infarction (AMI), with short-term mortality rates exceeding 40%. However, the definition of CS varies between trials, which may comprise interstudy comparability. Aim: The aim of the current study was to review differences and similarities of CS definitions used in randomized clinical trials (RCT) assessing patients with AMI-related CS. Methods: From the electronic databases MEDLINE and EMBASE we identified 19 AMI-related CS trials comprising a total of 2674 unique patients with CS. Results: Seven trials investigated left ventricular assist devices, eight investigated medical treatments, three percutaneous coronary interventions, and one trial investigated targeted temperature management. The inclusion criteria, baseline hemodynamics, endpoints and mortality varied markedly between trials. Hypotension was the most frequent inclusion criterion (17 (90%) trials), with a systolic blood pressure value <90mmHg combined with vasopressor use as the most frequent definition, Figure. Twelve (63%) trials had signs of impaired end-organ perfusion as an inclusion criterion and 10 (53%) signs of impaired cardiovascular function most frequently low cardiac index and reduced left ventricular ejection fraction. Ten (53%) trials included patients resuscitated from a cardiac arrest, three trials excluded cardiac arrest-patients whereas six trials did not state whether cardiac arrest was an exclusion criterion. Mortality ranged from 8 % to 73%. Conclusions: RCTs of AMI-related CS show marked heterogeneity in inclusion criteria and outcomes potentially hampering interstudy comparability. Consensus criteria for CS appear needed for future selection of patients.

Etiology and Prognosis of Cardiogenic Shock in a Secondary Center without Surgical Back-Up.

Background Cardiogenic shock (CS) remains a major challenge in contemporary cardiology. Data regarding CS etiologies and their prognosis are limited and mainly derived from tertiary referral centers. Aims To investigate the current etiologies of cardiogenic shock and their associated short- and long-term outcomes in a secondary center without surgical back-up. Methods We performed an observational prospective monocenter study. All patients admitted for a first episode of CS related to left ventricular dysfunction were enrolled. The definition of CS was consistent with the European Society of Cardiology guidelines. Patients were followed for 6 months. Etiologies were analyzed, and survival rates derived from Kaplan-Meier estimates were compared with the log-rank test. Results Between January 2015 and January 2016, 152 patients were included. The first most common cause of CS was acute decompensation of chronic heart failure (CHF). Acute coronary syndromes (ACS) were the second most common cause of CS (35.4%). At one month, the all-cause mortality rate was 39.5% and was similar between ACS and CHF (43% vs 35%, respectively; p=0.7). In a landmark analysis between 1 and 6 months, we observed a significantly higher mortality in patients with CHF than in patients with ACS (18% vs. 0%; p=0.01). Conclusions In the present registry, acute decompensation of chronic heart failure was the most common cause of CS, while ACS complicated by CS was the second most common cause. Of importance, acute decompensation of CHF was associated with a significantly worse outcome than ACS in the long term.

Panel 1 Patient selection

MODERATOR PENNINGTON: Our first panel for this morning is to deal with the important question of patient selection. In my own mind patient selection in applying these devices is extremely important and perhaps the most important issue. I don‘t know that we know the answers, but at least we have some guidelines that we will be able to offer you. The panelists are Dr John Burkholder from Allegheny Hospital in Pittsburgh, who has had extensive experience with the Bio-Medicus pump; Dr Walter Pae of HersheyPenn State, who has a large experience with the PierceDonachy and the Penn State Artificial Heart; and Dr Lyle Joyce from Minneapolis, who has had experience with the Jarvik heart and the centrifugal pumps. So, we have most of the various disciplines represented. I would submit this rather worn-out information (Table 1) to you as being still the criteria by which patients must be selected, that is, the definition of cardiogenic shock. After all, that is the group of patients we are concerned about in the application of virtually all these devices. The exact numbers, of course, are not so critical, but it is critical that we actually make the measurements. Cardiac output measurements in the operating room, for example, are absolutely essential to the use of these systems. One must measure the atrial pressures, and we believe it is absolutely essential that the left atrial pressure line be used, not a wedge pressure from a Swan catheter. All these measurements must be carefully made and repeated to be certain that they are accurate. The definition of maximal inotropic support is one that might be debated long and hard, but most of us know that when we are in the polypharmacy and our anesthesiologist is at his wit’s end with the patient still not making it, we have to offer more support. Almost all of our patients receive a balloon pump before the insertion of one of these devices. Whether these exact criteria would be agreeable to you or not is not important. The important thing is that the measurements be made and that some sort of systematic method be used to choose patients. Probably one of the most important things not stated in this table concerning postcardiotomy patients is that we must be absolutely certain that the operation that we set out to do has been done appropriately and properly. These devices are definitely not to be used to cover up inadequate or inefficient operations. So we want to be sure that the patient has had an optimal operation. Now, who should be excluded? The criteria we have adopted were somewhat difficult to come by, but these