Review on Management of Cardiogenic Shock
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Cardiogenic shock is a hemodynamically complex syndrome characterized by a low cardiac output that often culminates in multiorgan system failure and death. Despite recent advances, clinical outcomes remain poor, with mortality rates exceeding 40%. In the absence of adequately powered randomized controlled trials to guide therapy, best practices for shock management remain nonuniform.

Emerging data from North American registries, however, support the use of standardized protocols focused on rapid diagnosis, early intervention, ongoing hemodynamic assessment, and multidisciplinary longitudinal care. In this review, the authors examine the pathophysiology and phenotypes of cardiogenic shock, benefits and limitations of current therapies, and they propose a standardized and team-based treatment algorithm. They also discuss future research opportunities to address current gaps in clinical knowledge.

The following are key points to remember from this state-of-the-art review on management of cardiogenic shock:

1. Cardiogenic shock (CS) is a hemodynamically complex syndrome characterized by a low cardiac output that often culminates in multiorgan system failure and death.

2. Despite recent advances, clinical outcomes remain poor, with mortality rates exceeding 40%. In the absence of adequately powered randomized controlled trials to guide therapy, best practices for shock management remain nonuniform.

3. Emerging data from North American registries, support the use of standardized protocols focused on rapid diagnosis, early intervention, ongoing hemodynamic assessment, and multidisciplinary longitudinal care.

4. Effective emergency department triage is key to the early recognition and treatment of CS. In acute myocardial infarction (AMI)-CS, this means timely acquisition and interpretation of a 12-lead electrocardiogram by emergency medical personnel and immediate transfer to a percutaneous coronary intervention–capable facility.

5. Despite an absence of benefit of routine pulmonary artery catheter (PAC) use for heart failure, growing evidence supports the benefit of early invasive hemodynamic assessment in patients with CS. PAC use may lead to earlier and more accurate identification of the CS phenotype so that medical and device-based therapies may be applied in a tailored fashion.

6. Limited data support the use of norepinephrine as the preferred first-line agent, and retrospective analyses suggest similar outcomes with dobutamine and milrinone.

7. In the setting of dynamic and time-dependent complexities associated with AMI-CS complicated by cardiac arrest, a multidisciplinary approach to management is recommended with emphasis on evaluation of the patient’s overall prognosis, likelihood of a meaningful neurological recovery, and candidacy for revascularization and device-based therapies.

8. Selective deployment of mechanical circulatory support (MCS) in suitable patients with acute severe or refractory CS after expedited consultation with the multidisciplinary shock team, which consists of an interventional cardiologist, cardiothoracic surgeon, cardiac intensivist, and advanced heart failure specialist, is reasonable.

9. In select patients with left ventricular (LV)-dominant CS and normotensive hypoperfusion, pure vasodilators such as nitroprusside may improve cardiac output by reducing afterload, while the vasodilatory effects of milrinone and dobutamine can also be effective for high-afterload LV failure. Intravenous or inhaled pulmonary vasodilators reduce right ventricular (RV) afterload for pulmonary arterial hypertension and RV failure.

10. There is an urgent need for pragmatic randomized clinical trials for existing and emerging therapies to be adequately evaluated to further inform clinical practice including the optimal role of MCS.

Source: https://www.jacc.org/doi/10.1016/j.jchf.2020.09.005?_ga=2.93516190.2059416969.1603715169-777820309.1584504539&
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