Cardiogenic Shock and

Hemodynamics
 SHOCK= Inadequate Tissue Perfusion

• Mechanisms:
– Inadequate oxygen delivery
– Release of inflammatory mediators
– Further microvascular changes, compromised
blood flow and further cellular hypoperfusion

• Clinical Manifestations:
– Multiple organ failure
– Hypotension
 Hemodynamic Parameters
• Systemic Vascular Resistance (SVR)
• Cardiac Output (CO)
• Mixed Venous Oxygen Saturation (SvO2)
• Pulmonary Capillary Wedge Pressure (PCWP)
• Central Venous Pressure (CVP)
Differentiating Types of Shock
 Cardiogenic Shock
• Systemic hypoperfusion secondary to severe
depression of cardiac output and sustained
systolic arterial hypotension despite elevated
filling pressures.
 Cardiogenic Shock
• Etiologies
• Pathophysiology
• Clinical/Hemodynamic Characteristics
• Treatment Options
Pathophysiology
Cardiogenic
Shock
 Clinical Findings
• Physical Exam: elevated JVP, +S3, rales,
oliguria, acute pulmonary edema

• Hemodynamics: dec CO, inc SVR, dec SvO2

• Initial evaluation: hemodynamics (PA

catheter), echocardiography, angiography
 Classic Criteria for Diagnosis of Cardiogenic Shock

1. Systemic Hypotension
systolic arterial pressure < 80 mmHg
2. Persistent Hypotension
at least 30 minutes
3. Reduced Systolic Cardiac Function
Cardiac index < 1.8 x m²/min
4. Tissue Hypoperfusion
Oliguria, cold extremities, confusion
5. Increased Left Ventricular Filling
Pulmonary capillary wedge pressure > 18 mmHg
 Clinical Signs: Shock, Hypoperfusion, CHF, Acute Pulm Edema
Most likely major underlying disturbance?

Acute Pulmonary Hypovolemia Low-output Arrhythmia

Edema cardiogenic shock
Brady Tachy
Administer
Administer cardia cardia
Fluids
Furosemide
Blood transfusions
Morphine
Cause-specific See Sec. 7.7 in
Oxygen intubation
interventions Check Blood Pressure ACC/AHA
Nitroglycerin
Guidelines for
Dopamine
patients with STEMI
Dobutamine
Systolic Systolic BP
Check Blood Pressure BP (NO Systolic BP Systolic BP (<70 mm
(>100 mm signs/sympto (signs/symptoms Hg + signs/symptoms
Hg) ms of shock) of shock) of shock)
Systolic BP
(>100 mm Nitroglycerin Dobutamine Dopamine Norepinephrine
Hg)
Further Diagnostic/Therapeutic Considerations (for non-hypovolemic
shock)
ACE Diagnostic
Inhibitors Therapeutic
13
Pulmonary artery catheter, Intra-aortic
 4 Potential Therapies
• Pressors
• Intra-aortic Balloon Pump (IABP)
• Fibrinolytics
• Revascularization: CABG/PCI

• Refractory shock: ventricular assist device,

cardiac transplantation
Pressors do not change outcome

• Dopamine
– <2 renal vascular dilation
– <2-10 +chronotropic/inotropic (beta effects)
– >10 vasoconstriction (alpha effects)
• Dobutamine – positive inotrope, vasodilates,
arrhythmogenic at higher doses
• Norepinephrine (Levophed): vasoconstriction, inotropic
stimulant. Should only be used for refractory hypotension
with dec SVR.
• Vasopression – vasoconstriction
• VASO and LEVO should only be used as a last resort
Pharmacologic Treatment of
Cardiogenic Shock

• SBP <70 mm Hg + shock

→ Norepinephrine
• SBP 70-100 mm Hg + shock
→ Dopamine
• SBP 70-100 mm Hg – shock
→ Dobutamine
• Refractory hypotension + shock
→ Amrinone or milrinone may improve cardiac
output

16
ACC/AHA Guidelines 2004

Hochman Circ 2003: 107:298

 ACC/AHA Guidelines for Cardiogenic Shock

Class I
1. IABP is recommended for STEMI patients when
cardiogenic shock is not quickly reversed with
pharmacological therapy. The IABP is a stabilizing
measure for angiography and prompt
revascularization.
2. Intra-arterial monitoring is recommended for the
management of STEMI patients with cardiogenic
shock.
 ACC/AHA Guidelines for Cardiogenic Shock

Class I
1. Early revascularization, either PCI or CABG, is
recommended for patients < 75 years old with ST
elevation or new LBBB who develop shock unless
further support is futile due to patient’s wishes or
unsuitability for further invasive care.
2. Fibrinolytic therapy should be administered to STEMI
patients with cardiogenic shock who are unsuitable for
further invasive care and do not have contraindications
for fibrinolysis.
3. Echocardiography should be used to evaluate
mechanical complications unless assessed by invasively
 ACC/AHA Guidelines for Cardiogenic Shock
Class IIa

1. Pulmonary artery catheter monitoring can be useful for

the management of STEMI patients with cardiogenic
shock.
2. Early revascularization, either PCI or CABG, is
reasonable for selected patients > 75 years with ST
elevation or new LBBB who develop shock < 36
hours of MI and who are suitable for revascularization
that is performed < 18 hours of shock.
Patients with good prior functional status who agree to
invasive care may be selected for such an invasive
strategy.
 IABP is a temporizing measure
• Augments coronary blood flow in diastole

• Balloon collapse in systole creates a vacuum

effect  decreases afterload

• Decrease myocardial oxygen demand

 IABP

http://www.youtube.com/wat
ch?v=o11fhdVOYWA&feature=
player_detailpage

DSCP, Wikimedia Commons 22

Indication for IABP
 Contraindications to IABP
• Significant aortic regurgitation or significant arteriovenous
shunting
• Abdominal aortic aneurysm or aortic dissection
• Uncontrolled sepsis
• Uncontrolled bleeding disorder
• Severe bilateral peripheral vascular disease
• Bilateral femoral popliteal bypass grafts for severe peripheral
vascular disease.
 Complications of IABP
• Cholesterol Embolization
• CVA
• Sepsis
• Balloon rupture
• Thrombocytopenia
• Hemolysis
• Groin Infection
• Peripheral Neuropathy