Guidelines Summary
The following organizations have released guidelines that include recommendations for the management of cardiogenic shock:
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American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)
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European Society of Cardiology (ESC)
According to the 2013 ACCF/AHA guidelines for the management of ST-elevation myocardial infarction (STEMI), the greater the number of the following risk factors present, the higher the risk of developing cardiogenic shock [25] :
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Age >70 years
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Systolic blood pressure (BP) < 120 mm Hg
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Sinus tachycardia =110 bpm or heart rate (HR) < 60 bpm
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Increased time since onset of symptoms of STEMI
ST-elevation myocardial infarction
The 2013 ACCF/AHA guidelines for the management patients with STEMI who develop cardiogenic shock include the following [25] :
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Immediate transfer to a percutaneous coronary intervention (PCI)-capable hospital for coronary angiography for suitable patients (class I; level of evidence, B)
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Primary PCI should be performed, irrespective of time delay from the onset of myocardial infarction (MI) (class I; level of evidence, B)
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Urgent coronary artery bypass grafting (CABG) is indicated in patients with coronary anatomy not amenable to PCI (class I; level of evidence, B)
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Fibrinolytic therapy should be administered to patients who are unsuitable candidates for either PCI or CABG (class I; level of evidence, B)
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Beta blockers are contraindicated (class I; level of evidence, B)
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Intra-aortic balloon pump (IABP) counterpulsation can be useful for patients who do not quickly stabilize with pharmacologic therapy (class IIa; level of evidence, B)
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Alternative left ventricular (LV) assist devices (LVADs) for circulatory support may be considered in patients with refractory cardiogenic shock.(class IIb; level of evidence, C)
The 2015 ESC guidelines for the management of acute coronary syndromes (ACSs) concur with ACCF/AHA guidelines for STEMI. [11] However, the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure recommend against the routine use of IABP in the management of cardiogenic shock (class III; level of evidence, B), but short-term mechanical circulatory support (MCS) may be considered for managment of refractory cardiogenic shock in selected patients (class IIb; level of evidence, C). Additional recommendations for the management of cardiogenic shock include the following [56] :
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Rapid transfer to a tertiary center with round-the-clock cardiac catheterization capabilities, dedicated ICU/CCU with short-term MCS (class I; level of evidence, C)
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Immediate electrocardiography (ECG) and echocardiography for all patients with suspected cardiogenic shock (class I; level of evidence, C)
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Continous ECG and blood pressure monitoring (class I; level of evidence, C)
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Invasive monitoring with arterial line (class I; level of evidence, C)
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Coronary angiography withing 2 hours of hospital admission with the intent to perform coronary revascularization for patients with cardiogenic shock complicating ACS (class I; level of evidence, C)
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If there is no sign of fluid overload, saline or lactated Ringer solution >200 mL/15-30 min as the first-line treatment (class I; level of evidence, C)
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Consider IV dobutamine to increase cardiac output (class IIb; level of evidence, C)
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If there is a need to maintain systolic blood pressure in the presence of persistent hypoperfusion, consider vassopressors; norepinephrine is prefered to dopamine (class IIb; level of evidence, B)
Non–ST-elevation acute coronary syndromes
The 2014 AHA/American College of Cardiology (ACC) guideline for the management of patients with non–ST-elevation ACS (NSTE-ACS) includes the following recommendations for the management of cardiogenic shock [17] :
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Beta blockers are contraindicated when risk factors for cardiogenic shock are present (class III)
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Administer initial therapy with channel calcium blockers in patients with increased risk for cardiogenic shock (class I; level of evidence, B)
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For cardiogenic shock due to cardiac pump failure, early revascularization (class I; level of evidence, B)
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For refractory shock, IABP is reasonable (class IIa; level of evidence, C)
Mechanical circulatory support
The following organizations have released guidelines for the utilization of MCS:
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Society for Cardiovascular Angiography and Interventions (SCAI)/ACC/Heart Failure Society of America (HFSA)/Society of Thoracic Surgeons (STS)
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International Society of Heart and Lung Transplantation (ISHLT)
A 2015 clinical expert consensus statement from the SCAI/ACC/HFSA/STS noted that historically, the IABP and extracorporeal membrane oxygenation (ECMO) devices were the only MCS devices available to clinicians, but axial-flow pumps such as Impella and left atrium–to–femoral artery bypass pumps such as the TandemHeart subsequently entered clinical practice. The consensus-based recommendations included the following [57] :
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Percutaneous circulatory assist devices provide superior hemodynamic support compared with pharmacologic therapy; this is particularly apparent for the Impella and Tandem-Heart devices
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In those with cardiogenic shock who fail to stabilize or show signs of improvement after initial interventions, early placement of an appropriate MCS may be considered
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For cardiogenic shock, IABP is less likely to provide benefit than continuous-flow pumps, including the Impella CP and TandemHeart
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ECMO may also provide benefit, particularly for patients with impaired respiratory gas exchange
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MCS may be considered for isolated acute right ventricular failure complicated by cardiogenic shock
In its 2013 guidelines for mechanical circulatory support, the ISHLT recommended long-term MCS for acute cardiogenic shock in the following groups (class IIa; level of evidence, C) [58] :
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Patients whose ventricular function is deemed unrecoverable or unlikely to recover without long-term device support.
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Patients who are deemed too ill to maintain normal hemodynamics and vital organ function with temporary MCS, or who cannot be weaned from temporary MCS or inotropic support.
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Patients with the capacity for meaningful recovery of end-organ function and quality of life.
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Patients without irreversible end-organ damage
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Cardiogenic shock. This image was obtained from a patient with an acute anterolateral myocardial infarction who developed cardiogenic shock. Coronary angiography images showed severe stenosis of the left anterior descending coronary artery, which was dilated by percutaneous transluminal coronary angioplasty.
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Cardiogenic shock. This coronary angiogram from a patient with cardiogenic shock demonstrates severe stenosis of the right coronary artery.
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Cardiogenic shock. This coronary angiogram from a patient with cardiogenic shock reveals severe stenosis of the right coronary artery. Following angioplasty of the critical stenosis, coronary flow was reestablished. The patient recovered from cardiogenic shock.
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Cardiogenic shock. This electrocardiogram shows evidence of an extensive anterolateral myocardial infarction. The patient subsequently developed cardiogenic shock.
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Cardiogenic shock. The electrocardiogram tracing shows further evolutionary changes in a patient with cardiogenic shock.
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Cardiogenic shock. The electrocardiogram tracing was obtained from a patient who developed cardiogenic shock secondary to pericarditis and pericardial tamponade.
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Cardiogenic shock. A 63-year-old man was admitted to the emergency department with clinical features of cardiogenic shock. The electrocardiogram revealed findings indicative of wide-complex tachycardia, likely ventricular tachycardia. Following cardioversion, his shock state improved. Myocardial ischemia was the cause of the ventricular tachycardia.
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Cardiogenic shock. A short-axis view of the left ventricle demonstrates small pericardial effusion, low ejection fraction, and segmental wall motion abnormalities. Courtesy of Michael Stone, MD, RDMS.
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Cardiogenic shock. Pleural sliding in an intercostal space demonstrates increased lung comet artifacts suggestive of pulmonary edema. Courtesy of Michael Stone, MD, RDMS.
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Cardiogenic shock. HeartMate II Left Ventricular Assist Device. Reprinted with the permission of Thoratec Corporation.
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