Cardiogenic Shock: From Reperfusion to Revascularization and Hemodynamic Support
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Amar R. Chadaga, MD, Jamil B. Dihu, MD, Timothy A. Sanborn, MD
Abstract
Cardiogenic shock represents the most ominous challenge of acute myocardial infarction (AMI), with an incidence of 8–9% and a mortality rate approaching 50%. The majority of cases of cardiogenic shock are secondary to AMI complicated by left ventricular failure leading to refractory hypoperfusion and hypotension. Placement of an intra-aortic balloon pump (IABP) and primary percutaneous coronary intervention (PCI), particularly in young patients, remain the American College of Cardiology (ACC)/American Heart Association (AHA) Class 1 recommendations in those suffering from cardiogenic shock. Prompt triage of all patients in cardiogenic shock for early angiography, IABP counterpulsation, and early revascularization with PCI or bypass surgery is now the preferred management strategy. The purpose of this review is to summarize the care of these critically ill patients, including the consideration of basic pharmacologic and interventional techniques and novel therapies as well.
Key words: myocardial infarction, anticoagulation, percutaneous coronary intervention, new devices
VASCULAR DISEASE MANAGEMENT 2010;7:E46–E54
Case Presentation
A 78-year-old female with no prior cardiac history presented with 1 week of intermittent burning in the chest, which progressed to remaining constant on the day she presented to our center. The pain, however, had abated upon her arrival to the emergency department. The patient’s blood pressure was 102/64 mmHg, she had a heart rate of 114 beats/minute, and no murmurs or gallops were heard on auscultation. An electrocardiogram (ECG) revealed ST depression in the lateral leads. Her troponin was 2.5 µg/L, while her CK-MB U/L was 22.50 and her myoglobin was 170 µg/L. The patient was started on oxygen, intravenous fluids, aspirin, beta-blockade, heparin, integrilin, clopidogrel, and a statin. At 5:00 am her blood pressure was 64/27 mmHg and her pulmonary examination revealed rales.
Question: What treatment strategy would be most appropriate in this case?
Introduction
A diagnosis of cardiogenic shock portends a grave outcome in acute myocardial infarction (AMI), with historic mortality rates ranging from 70– 90%.1–3 Though the pathophysiology varies, this article will focus primarily on cardiogenic shock as a complication of an AMI with subsequent left ventricular failure leading to refractory hypotension and hypoperfusion.4–6 Historically, the frequency with which cardiogenic shock complicates AMI has remained unchanged at approximately 8–9%.1,3,7
An encouraging trend in recent investigations has emerged to show a decreased incidence of cardiogenic shock and a lower mortality rate as well.7–10 Improvements in mortality and incidence are thought to reflect the increased use of intra-aortic balloon pump (IABP) counterpulsation and emergent coronary reperfusion strategies.11 Data from 775 hospitals with revascularization capabilities found that mortality rates from cardiogenic shock dropped from 60.3% in 1995 to 47.9% in 2004, according to data retrieved from the Second, Third, and Fourth National Registry of Myocardial Infarction (NRMI-2, NRMI-3, NRMI-4).12 Not surprisingly, placement of an IABP and primary percutaneous coronary intervention (PCI) in patients ≤ 75 years of age are American College of Cardiology (ACC)/American Heart Association (AHA) Class 1 recommendations in those suffering from cardiogenic shock.13,14
Despite noted improvements, the mortality rates from cardiogenic shock continue to be unacceptably high. The medical community has responded with a variety of measures including evaluating the appropriate mode and time of revascularization in patients with cardiogenic shock. Improvement in the understanding and management of cardiogenic shock has also been achieved through the use of pharmacologic regimens and percutaneous ventricular assist devices. A description of the current pharmacologic and percutaneous interventional techniques, consensus guidelines, and emerging technologies relating to cardiogenic shock is presented in this article.
Pharmacologic Therapy
Aspirin, heparin, and GP IIb/IIIa inhibitors. The medical therapies used in the setting of an AMI have not been specifically studied in the subgroup of patients with cardiogenic shock, though their use as it pertains to reperfusion should strongly be considered. These therapies are outlined in the AHA/ACC Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction and Unstable Angina/Non-ST-Elevation Myocardial Infarction.13,15
Aspirin, through its ability to irreversibly block thromboxane A2 production, has long been studied to prevent platelet adhesion after the rupture of an atherosclerotic plaque. Meta-analyses of several trials evaluating the role of aspirin in acute coronary syndromes (ACS) have revealed reduced vascular events, recurrent ischemia, and coronary reocclusion rates in patients receiving aspirin.16,17 Data supporting the use of aspirin in ACS has led to a Class 1 designation within the ACC/AHA Guidelines for the use of chewable aspirin (dose 162–325 mg) in patients with unstable angina (UA)/non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) who are not known to be intolerant.13,15 A preference for chewable aspirin is guided by the fact that buccal absorption is more rapid than is the case with enteric-coated aspirin.18
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