Cardiogenic Shock Clinical Presentation
- Author: Xiushui (Mike) Ren, MD; Chief Editor: Henry H Ooi, MD, MRCPI more...
Cardiogenic shock is a medical emergency. A complete clinical assessment is critical to understanding the cause of the shock and to targeting therapy for correcting the cause. The presenting history will vary depending on the underlying etiology of cardiogenic shock.
Cardiogenic shock following acute MI generally develops after admission to the hospital, although a small number of patients are in shock at presentation. Patients demonstrate clinical evidence of hypoperfusion (low cardiac output), which is manifested by sinus tachycardia, low urine output, and cool extremities. Systemic hypotension, defined as systolic blood pressure below 90 mm Hg or a decrease in mean blood pressure by 30 mm Hg, ultimately develops and further propagates tissue hypoperfusion.
Most patients who develop acute MI present with an abrupt onset of squeezing or heavy substernal chest pain; the pain may radiate to the left arm or the neck. The chest pain may be atypical, the location being epigastric or only in the neck or arm. The pain quality may be burning, sharp, or stabbing. Pain may be absent in persons with diabetes or in elderly individuals.
Patients also may report associated autonomic symptoms, including nausea, vomiting, and sweating.
A history of previous cardiac disease, use of cocaine, previous myocardial infarction (MI), or previous cardiac surgery should be obtained. A patient thought to have myocardial ischemia should be assessed for cardiac risk factors. The evaluation should reveal a history of hyperlipidemia, left ventricular hypertrophy, hypertension, or cigarette smoking or a family history of premature coronary artery disease. The presence of 2 or more risk factors increases the likelihood of acute MI.
Other associated symptoms are diaphoresis, exertional dyspnea, or dyspnea at rest. Presyncope or syncope, palpitations, generalized anxiety, and depression are other features indicative of poor cardiac function.
Cardiogenic shock is diagnosed after documentation of myocardial dysfunction and exclusion of alternative causes of hypotension, such as hypovolemia, hemorrhage, sepsis, pulmonary embolism, pericardial tamponade, aortic dissection, or preexisting valvular disease. Shock is present if evidence of multisystem organ hypoperfusion in the presence of hypotension is detected upon physical examination (systolic blood pressure <90 mm Hg, cardiac index <2.2 L/min/m2, and in the presence of normal or elevated pulmonary capillary occlusion pressure [>15 mm Hg], or right ventricular end-diastolic pressure [RVEDP] [>10 mm Hg]).
Characteristics of patients with cardiogenic shock include the following:
Patients in shock usually appear ashen or cyanotic and have cool skin and mottled extremities
Peripheral pulses are rapid and faint and may be irregular if arrhythmias are present
Jugular venous distention and crackles in the lungs are usually (but not always) present; peripheral edema also may be present.
Heart sounds are usually distant, and third and fourth heart sounds may be present
The pulse pressure may be low, and patients are usually tachycardic
Patients show signs of hypoperfusion, such as altered mental status and decreased urine output
A systolic murmur is generally heard in patients with acute mitral regurgitation or ventricular septal rupture. The associated parasternal thrill indicates the presence of a ventricular septal defect, whereas the murmur of mitral regurgitation may be limited to early systole. Approximately two thirds of patients will develop pulmonary congestion manifested as rales on pulmonary examination.
The systolic murmur, which becomes louder upon Valsalva and prompt standing, suggests hypertrophic obstructive cardiomyopathy (idiopathic hypertropic subaortic stenosis).
Alonso DR, Scheidt S, Post M, Killip T. Pathophysiology of cardiogenic shock. Quantification of myocardial necrosis, clinical, pathologic and electrocardiographic correlations. Circulation. 1973 Sep. 48 (3):588-96. [Medline].
Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation. 2008 Feb 5. 117(5):686-97. [Medline].
Funaro S, La Torre G, Madonna M, et al, for the AMICI Investigators. Incidence, determinants, and prognostic value of reverse left ventricular remodelling after primary percutaneous coronary intervention: results of the Acute Myocardial Infarction Contrast Imaging (AMICI) multicenter study. Eur Heart J. 2009 Mar. 30 (5):566-75. [Medline].
Forrester JS, Wyatt HL, Da Luz PL, Tyberg JV, Diamond GA, Swan HJ. Functional significance of regional ischemic contraction abnormalities. Circulation. 1976 Jul. 54 (1):64-70. [Medline].
Beyersdorf F, Buckberg GD, Acar C, et al. Cardiogenic shock after acute coronary occlusion. Pathogenesis, early diagnosis, and treatment. Thorac Cardiovasc Surg. 1989 Feb. 37 (1):28-36. [Medline].
Al-Reesi A, Al-Zadjali N, Perry J, et al. Do beta-blockers reduce short-term mortality following acute myocardial infarction? A systematic review and meta-analysis. CJEM. 2008 May. 10(3):215-23. [Medline].
Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005 Nov 5. 366(9497):1622-32. [Medline].
Kolte D, Khera S, Aronow WS, et al. Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States. J Am Heart Assoc. 2014 Jan 13. 3 (1):e000590. [Medline].
Goldberg RJ, Samad NA, Yarzebski J, Gurwitz J, Bigelow C, Gore JM. Temporal trends in cardiogenic shock complicating acute myocardial infarction. N Engl J Med. 1999 Apr 15. 340(15):1162-8. [Medline].
Roffi M, Patrono C, Collet JP, et al, for the European Society of Cardiology Task Force. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2015 Aug 29. [Medline].
Graf T, Desch S, Eitel I, Thiele H. Acute myocardial infarction and cardiogenic shock: pharmacologic and mechanical hemodynamic support pathways. Coron Artery Dis. 2015 Sep. 26 (6):535-44. [Medline].
Babaev A, Frederick PD, Pasta DJ, Every N, Sichrovsky T, Hochman JS. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA. 2005 Jul 27. 294(4):448-54. [Medline].
Fox KA, Steg PG, Eagle KA, Goodman SG, Anderson FA Jr, Granger CB, et al. Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006. JAMA. 2007 May 2. 297(17):1892-900. [Medline].
Jeger RV, Radovanovic D, Hunziker PR, Pfisterer ME, Stauffer JC, Erne P, et al. Ten-year trends in the incidence and treatment of cardiogenic shock. Ann Intern Med. 2008 Nov 4. 149(9):618-26. [Medline].
Amsterdam EA, Wenger NK, Brindis RG, et al, for the ACC, AHA Task Force on Practice Guidelines, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23. 64 (24):e139-228. [Medline].
Kunadian V, Qiu W, Ludman P, et al, for the National Institute for Cardiovascular Outcomes Research. Outcomes in patients with cardiogenic shock following percutaneous coronary intervention in the contemporary era: an analysis from the BCIS database (British Cardiovascular Intervention Society). JACC Cardiovasc Interv. 2014 Dec. 7 (12):1374-85. [Medline].
Hamon M, Agostini D, Le Page O, Riddell JW, Hamon M. Prognostic impact of right ventricular involvement in patients with acute myocardial infarction: meta-analysis. Crit Care Med. 2008 Jul. 36(7):2023-33. [Medline].
Hasdai D, Califf RM, Thompson TD, Hochman JS, Ohman EM, Pfisterer M, et al. Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction. J Am Coll Cardiol. 2000 Jan. 35(1):136-43. [Medline].
Picard MH, Davidoff R, Sleeper LA, and the SHOCK Trial investigators. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK. Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock. Circulation. 2003 Jan 21. 107 (2):279-84. [Medline].
Jeger RV, Lowe AM, Buller CE, Pfisterer ME, Dzavik V, Webb JG, et al. Hemodynamic parameters are prognostically important in cardiogenic shock but similar following early revascularization or initial medical stabilization: a report from the SHOCK Trial. Chest. 2007 Dec. 132(6):1794-803. [Medline].
O'Gara PT, Kushner FG, Ascheim DD, et al, for the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29. 127 (4):e362-425. [Medline].
Hochman JS, Sleeper LA, White HD, Dzavik V, Wong SC, Menon V, et al. One-year survival following early revascularization for cardiogenic shock. JAMA. 2001 Jan 10. 285(2):190-2. [Medline].
Shin TG, Choi JH, Jo IJ, Sim MS, Song HG, Jeong YK, et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation. Crit Care Med. 2011 Jan. 39(1):1-7. [Medline].
De Backer D, Biston P, Devriendt J, et al, for the SOAP II Investigators. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010 Mar 4. 362 (9):779-89. [Medline].
Ellender TJ, Skinner JC. The use of vasopressors and inotropes in the emergency medical treatment of shock. Emerg Med Clin North Am. 2008 Aug. 26(3):759-86, ix. [Medline].
Naples RM, Harris JW, Ghaemmaghami CA. Critical care aspects in the management of patients with acute coronary syndromes. Emerg Med Clin North Am. 2008 Aug. 26(3):685-702, viii. [Medline].
Felker GM, Benza RL, Chandler AB, et al, for the OPTIME-CHF Investigators. Heart failure etiology and response to milrinone in decompensated heart failure: results from the OPTIME-CHF study. J Am Coll Cardiol. 2003 Mar 19. 41 (6):997-1003. [Medline].
Gheorghiade M, Gattis WA, Klein L. OPTIME in CHF trial: rethinking the use of inotropes in the management of worsening chronic heart failure resulting in hospitalization. Eur J Heart Fail. 2003 Jan. 5 (1):9-12. [Medline].
Fuhrmann JT, Schmeisser A, Schulze MR, Wunderlich C, Schoen SP, Rauwolf T, et al. Levosimendan is superior to enoximone in refractory cardiogenic shock complicating acute myocardial infarction. Crit Care Med. 2008 Aug. 36(8):2257-66. [Medline].
De Luca L, Colucci WS, Nieminen MS, Massie BM, Gheorghiade M. Evidence-based use of levosimendan in different clinical settings. Eur Heart J. 2006 Aug. 27(16):1908-20. [Medline].
Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet. 1986 Feb 22. 1 (8478):397-402. [Medline].
Gruppo Italiano per lo Studio della Streptochi-nasi nell'Infarto Miocardico (GISSI). Long-term effects of intravenous thrombolysis in acute myocardial infarction: final report of the GISSI study. Lancet. 1987 Oct 17. 2 (8564):871-4. [Medline].
Sanborn TA, Sleeper LA, Bates ER, et al. Impact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?. J Am Coll Cardiol. 2000 Sep. 36(3 Suppl A):1123-9. [Medline].
Garatti A, Russo C, Lanfranconi M, Colombo T, Bruschi G, Trunfio S, et al. Mechanical circulatory support for cardiogenic shock complicating acute myocardial infarction: an experimental and clinical review. ASAIO J. 2007 May-Jun. 53(3):278-87. [Medline].
Cheng JM, den Uil CA, Hoeks SE, van der Ent M, Jewbali LS, van Domburg RT, et al. Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a meta-analysis of controlled trials. Eur Heart J. 2009 Sep. 30(17):2102-8. [Medline].
Sjauw KD, Engstrom AE, Vis MM, et al. A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines?. Eur Heart J. 2009 Feb. 30 (4):459-68. [Medline].
Ramanathan K, Farkouh ME, Cosmi JE, French JK, Harkness SM, Džavík V, et al. Rapid complete reversal of systemic hypoperfusion after intra-aortic balloon pump counterpulsation and survival in cardiogenic shock complicating an acute myocardial infarction. Am Heart J. 2011 Aug. 162(2):268-75. [Medline]. [Full Text].
Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012 Oct 4. 367(14):1287-96. [Medline].
Windecker S. Percutaneous left ventricular assist devices for treatment of patients with cardiogenic shock. Curr Opin Crit Care. 2007 Oct. 13(5):521-7. [Medline].
Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001 Nov 15. 345(20):1435-43. [Medline].
Farrar DJ, Lawson JH, Litwak P, Cederwall G. Thoratec VAD system as a bridge to heart transplantation. J Heart Transplant. 1990 Jul-Aug. 9(4):415-22; discussion 422-3. [Medline].
Damme L, Heatley J, Radovancevic B. Clinical results with the HeartMate LVAD: Worldwide Registry update. J Congestive Heart Failure Circ Support. 2001. 2:5-7(3).
Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med. 1999 Aug 26. 341(9):625-34. [Medline].
Antoniucci D, Valenti R, Migliorini A, Moschi G, Trapani M, Buonamici P, et al. Relation of time to treatment and mortality in patients with acute myocardial infarction undergoing primary coronary angioplasty. Am J Cardiol. 2002 Jun 1. 89(11):1248-52. [Medline].
Antman EM, Anbe DT, Armstrong PW, et al, for the American College of Cardiology, American Heart Association, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004 Aug 4. 44 (3):671-719. [Medline].
Hochman JS, Boland J, Sleeper LA, Porway M, Brinker J, Col J, et al. Current spectrum of cardiogenic shock and effect of early revascularization on mortality. Results of an International Registry. SHOCK Registry Investigators. Circulation. 1995 Feb 1. 91(3):873-81. [Medline].
Jeger RV, Harkness SM, Ramanathan K, et al, for the SHOCK Investigators. Emergency revascularization in patients with cardiogenic shock on admission: a report from the SHOCK trial and registry. Eur Heart J. 2006 Mar. 27 (6):664-70. [Medline].
Hochman JS, Sleeper LA, Webb JG, et al, for the SHOCK Investigators. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA. 2006 Jun 7. 295 (21):2511-5. [Medline].
Slottosch I, Liakopoulos O, Kuhn E, Deppe AC, Scherner M, Madershahian N, Choi YH, Wahlers T. Outcomes after peripheral extracorporeal membrane oxygenation therapy for postcardiotomy cardiogenic shock: a single-center experience. J Surg Res. 2013 May 15;181(2):e47-55. doi: 10.1016/j.jss.2012.07.030. Epub 2012 Aug 1. [Medline].
Anderson ML, Peterson ED, Peng SA, et al. Differences in the profile, treatment, and prognosis of patients with cardiogenic shock by myocardial infarction classification: A report from NCDR. Circ Cardiovasc Qual Outcomes. 2013 Nov. 6 (6):708-15. [Medline].
Menon V, White H, LeJemtel T, et al. The clinical profile of patients with suspected cardiogenic shock due to predominant left ventricular failure: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?. J Am Coll Cardiol. 2000 Sep. 36 (3 suppl A):1071-6. [Medline].
Koprivanac M, Kelava M, Soltesz E, et al. Advances in temporary mechanical support for treatment of cardiogenic shock. Expert Rev Med Devices. 2015 Nov. 12 (6):689-702. [Medline].
Susen S, Rauch A, Van Belle E, Vincentelli A, Lenting PJ. Circulatory support devices: fundamental aspects and clinical management of bleeding and thrombosis. J Thromb Haemost. 2015 Oct. 13 (10):1757-67. [Medline].