Shock Cardiogenico

Cardiogenic Shock: Current Concepts and Improving Outcomes
Harmony R. Reynolds and Judith S. Hochman
Circulation 2008;117;686-697
DOI: 10.1161/CIRCULATIONAHA.106.613596
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Contemporary Reviews in Cardiovascular Medicine
Cardiogenic Shock
Current Concepts and ImprovingOutcomes
Harmony R. Reynolds, MD; Judith S. Hochman, MD

C

ardiogenic shock (CS) occurs in 5% to 8% of patients
hospitalized with ST-elevation myocardial infarction
(STEMI). Recent research has suggested that the peripheral
vasculature and neurohormonal and cytokine systems play a
role in the pathogenesis and persistence of CS. Early revascularization for CS improves survivalsubstantially. New
mechanical approaches to treatment are available, and clinical
trials are feasible even in this high-risk population. Most
importantly, hospital survivors have an excellent chance for
long-term survival with good quality of life. This review will
outline the causes, pathophysiology, and treatment of CS with
a focus on CS complicating myocardial infarction (MI.) The
case will be madefor viewing CS as a serious disorder with
a high early death rate, but one that is treatable and that, if
approached aggressively, can result in full recovery.

Diagnosis and Causes
CS is a state of end-organ hypoperfusion due to cardiac
failure. The definition of CS includes hemodynamic parameters: persistent hypotension (systolic blood pressure 80 to
90 mm Hg or mean arterial pressure 30mm Hg lower than
baseline) with severe reduction in cardiac index ( 1.8 L ·
min 1 · m 2 without support or 2.0 to 2.2 L · min 1 · m 2
with support) and adequate or elevated filling pressure (eg,
left ventricular [LV] end-diastolic pressure 18 mm Hg or
right ventricular [RV] end-diastolic pressure
10 to
15 mm Hg). The diagnosis is usually made with the help of
pulmonary artery (PA)catheterization; however, Doppler
echocardiography may also be used to confirm elevation of
LV filling pressures.1 Hypoperfusion may be manifest clinically by cool extremities, decreased urine output, and/or
alteration in mental status. Hemodynamic abnormalities form
a spectrum that ranges from mild hypoperfusion to profound
shock, and the short-term outcome is directly related to the
severity ofhemodynamic derangement.
MI with LV failure remains the most common cause of CS.
It is critical to exclude complicating factors that may cause
shock in MI patients. Chief among these are the mechanical
complications: ventricular septal rupture, contained free wall
rupture, and papillary muscle rupture. Mechanical complications must be strongly suspected in patients with CS complicatingnonanterior MI, particularly a first MI. Echocardiography is the technique of choice to rule out these entities and

should be performed early unless the diagnosis is extensive
anterior MI and the patient is undergoing prompt percutaneous coronary intervention (PCI). In addition, the detection of
valvular disease before angiography may alter the revascularization approach.
Hemorrhage, infection,...