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Med Clin N Am 91 (2007) 713–727

Cardiogenic Shock: Treatment
Zaza Iakobishvili, MD, PhDa,b, David Hasdai, MDa,b,*

Intensive Cardiac Care Unit, Department of Cardiology, Rabin Medical Center, Beilinson Campus, 39 Jabotinsky Street, Petah Tikva, Israel 49100 b Tel Aviv University, P.O. Box 39040, Tel Aviv 69978, Israel

The treatment of cardiogenic shock patients consists of medicaltherapy, percutaneous revascularization procedures, cardiac surgery, and the implantation of devices. Because of the extreme complexity of their management, cardiogenic shock patients require reliable and precise hemodynamic monitoring. Invasive systemic blood pressure monitoring is highly recommended. In addition, many authorities advocate use of right heart catheterization or echocardiography forguiding therapeutic measures.

Right heart catheterization The role of right heart catheterization in the management of cardiogenic shock patients remains controversial. On one hand, there are retrospective data on increased mortality hazard associated with this procedure [1]. On the other hand, data from the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-I) trial [2] andthe Should We Emergently Revascularize Occluded Coronaries in Cardiogenic Shock? (SHOCK) registry [3] suggest that it is not harmful, and possibly beneficial, in terms of outcome. The mortality rate was lower in patients who underwent right heart catheterization than in those who did not (45.2% versus 63.4%) in the GUSTO-I population. In the SHOCK registry, no increase was reported in thein-hospital mortality among patients undergoing right heart catheterization [3]. The current American and European guidelines recommend right heart catheterization for patients who have ST-elevation acute coronary

* Corresponding author. Intensive Cardiac Care Unit, Department of Cardiology, Rabin Medical Center, Beilinson Campus, 39 Jabotinsky Street, Petah Tikva, Israel 49100. E-mail address:dhasdai@post.tau.ac.il (D. Hasdai). 0025-7125/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.mcna.2007.02.007 medical.theclinics.com



syndromes (ACS), or who have progressive heart failure, cardiogenic shock, or mechanical complications, despite the paucity of evidence proving its efficacy [4,5]; however, the implementation of theseguidelines is rather poor in current clinical practice. According to the Euro-Heart-ACS Survey, among 549 cardiogenic shock patients, right heart catheterization was performed only in 20.2% of cases [6]. It should be stressed that there are no data regarding the optimal hemodynamic values to be targeted in cardiogenic shock patients.

Echocardiography Doppler echocardiography is an excellentbedside tool for hemodynamic assessment and for the evaluation of cardiac function, valvular status, and mechanical complications of ACS [7]. Its use has steadily increased over the years, and currently it is performed routinely among ACS patients in many institutions. Its use is also increasing among cardiogenic shock patients. In the SHOCK trial, 175 echocardiograms were performed within 24 hours ofrandomization [8]. In the Euro-Heart-ACS Survey, 68% of cardiogenic shock patients underwent an echocardiographic evaluation [7]. Perhaps this noninvasive, readily available method has supplanted right heart catheterization use in most situations.

Drug therapy Inotropes A mean arterial pressure of 60 mm Hg is generally necessary for tissue perfusion. Experience in patients who have septicshock has shown that further elevation of the mean blood pressure by norepinephrine did not further improve systemic perfusion, but did increase myocardial oxygen demands [9]. Large-scale controlled studies have not been performed to compare different combinations of inotropes in patients who have cardiogenic shock. Their efficacy can be influenced by the local tissue perfusion and metabolism that are...
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