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    5.2 DR - Yusuf Assegaf SPJP - Syok Kardiogenik

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    Afdol Triatmojo Sikumbang
    Cardiogenic shock is a condition caused by cardiac dysfunction leading to inadequate tissue perfusion and hypotension. It has a high in-hospital mortality rate of 50-80% and is most often caused by acute myocardial infarction. Key features include low cardiac output, elevated left ventricular filling pressures, and signs of hypoperfusion. Treatment involves identifying the underlying cause, providing hemodynamic support with inotropes or vasopressors, and considering mechanical support such as intra-aortic balloon pumps or left ventricular assist devices for refractory cases.

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    5.2 DR - Yusuf Assegaf SPJP - Syok Kardiogenik

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    Afdol Triatmojo Sikumbang
    466 views33 pages
    Cardiogenic shock is a condition caused by cardiac dysfunction leading to inadequate tissue perfusion and hypotension. It has a high in-hospital mortality rate of 50-80% and is most often caused by acute myocardial infarction. Key features include low cardiac output, elevated left ventricular filling pressures, and signs of hypoperfusion. Treatment involves identifying the underlying cause, providing hemodynamic support with inotropes or vasopressors, and considering mechanical support such as intra-aortic balloon pumps or left ventricular assist devices for refractory cases.

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    5.2 Dr.yusuf Assegaf SpJP - Syok Kardiogenik

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    Cardiogenic shock is a condition caused by cardiac dysfunction leading to inadequate tissue perfusion and hypotension. It has a high in-hospital mortality rate of 50-80% and is most often caused by acute myocardial infarction. Key features include low cardiac output, elevated left ventricular filling pressures, and signs of hypoperfusion. Treatment involves identifying the underlying cause, providing hemodynamic support with inotropes or vasopressors, and considering mechanical support such as intra-aortic balloon pumps or left ventricular assist devices for refractory cases.

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    466 views33 pages

    5.2 DR - Yusuf Assegaf SPJP - Syok Kardiogenik

    Uploaded by

    Afdol Triatmojo Sikumbang
    Cardiogenic shock is a condition caused by cardiac dysfunction leading to inadequate tissue perfusion and hypotension. It has a high in-hospital mortality rate of 50-80% and is most often caused by acute myocardial infarction. Key features include low cardiac output, elevated left ventricular filling pressures, and signs of hypoperfusion. Treatment involves identifying the underlying cause, providing hemodynamic support with inotropes or vasopressors, and considering mechanical support such as intra-aortic balloon pumps or left ventricular assist devices for refractory cases.

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    of 33

    CARDIOGENIC SHOCK

    Department of Cardiology and Vascular Medicine


    Airlangga School of Medicine - Dr. Soetomo Teaching Hospital Surabaya
    Mochamad Yusuf, MD FIHA
    Rika Yenni P, MD
    Rommy, MD
    BACKGROUND
    BACKGROUND
    Some facts:
    The incidence remained stable
    over the past 3 decades
    I n-hospi tal mortal i ty: 60%
    (SHOCK Trial Registry) and
    50-80% (older series)
    Mostly after reaching hospital
    Brain: Altered mental status
    CIRCULATORY SHOCK
    Kidney: Oliguria
    Skin: Mottled, clammy
    Tachycardia
    Blood lactate !
    Arterial hypotension
    Absent
    Chronic
    hypotension?
    Syncope (if
    transient)
    Vincent JL, 2013
    CIRCULATORY SHOCK
    Distributive non-septic
    4%
    Cardiogenic
    16%
    Hypovolemic
    16%
    Obstructive
    2%
    Distributive septic
    62%
    Normal chamber & usually
    preserved contractility
    Distributive Shock Cardiogenic Shock
    Large ventricle & poor
    contractility
    In tamponade: pericardial effusion,
    small RV & LV, dilated IVC; in
    pulmonary embolism or
    pneumothorax: dilated RV, small LV
    Obstructive Shock
    Small chamber & normal/
    high contractility
    Hypovolemic Shock
    Brain: Altered mental status
    Kidney: Oliguria
    Skin: Mottled, clammy
    Tachycardia
    Blood lactate !
    CIRCULATORY SHOCK
    Arterial hypotension
    Present
    Circulatory
    shock
    Est. CO or S
    VO2
    Normal
    or high
    Low
    Low
    CVP
    High
    CVP
    Distributive
    shock
    Hypovolemic
    shock
    Cardiogenic
    & obstructive
    shock
    Shock: clinical expression of circulatory failure
    that results in inadequate cellular oxygen
    utilization.
    Vincent JL, 2013
    Cardiogenic Shock
    Large ventricle & poor
    contractility
    CARDIOGENIC SHOCK
    Persistent hypotension and tissue hypoperfusion
    due to cardiac dysfunction with adequate
    intravascular volume and LV lling pressure.
    Hypotension, tachycardia, oliguria, cool extremities & altered mental status

    Sustained hypotension: SBP < 90 mm Hg for 30 mins

    Low cardiac index: <1.8 L/min/m2 (supported) or 2.0


    -2.2 L/min/m2 (unsupported)

    Elevated PCWP: >15 mmHg



    Clinical Sign

    Hemodynamic Finding
    ETIOLOGY
    LV Failure
    78%
    MR
    7%
    VSR
    4%
    RV infarct
    3%
    Tamponade / Free wall rupture
    1%
    Others
    7%
    Causes of Cardiogenic shock in AMI
    (SHOCK trial)
    Topalian, 2008
    Cardiac:

    Acute myocardial infarction

    End-stage cardiomyopathy

    Myocarditis

    LVOT obstruction (AS / HOCM)

    Obstruction to LV lling (MS / LA


    myxoma)

    Acute mitral / aortic regurgitation


    (chordal rupture)

    Tamponade
    Non Cardiac:

    Severe pulmonary arterial


    hypertension

    Acute severe pulmonary embolism


    PATHOPHYSIOLOGY
    Acute MI
    LV Dysfunction
    Systolic Diastolic
    Ischemia
    Progresive
    LV Dysfunction
    Death
    LVEDP !
    Lung Edema
    Hypoxia
    Cardiac Output "
    Stroke Volume "
    Hypotension
    Coronary
    perfusion "
    Peripheral
    perfusion "
    Vasoconstriction
    Fluid retention
    SIRS
    SVR "

    Pro-inammation
    Cathecolamin sensitivity"
    Contractility "
    NO !
    Peroxynitrite !
    IL-6 !
    TNF-# !

    eNOS

    iNOS
    Inotropes /
    Vasopressors
    x
    Mechanical supports:
    IABP/LVAD
    x
    Reperfusions:
    PCI/CABG
    x
    MYOCARDIAL ISCHEMIA
    Cell
    death
    No return
    of function
    Reperfusion
    Signicant
    residual stenosis
    Myocardial
    stunning
    Both stunning
    & hibernation
    Myocardial
    hibernating
    Innotropic
    support
    Relief of
    ischemia
    Return of
    function
    Hollenberg, 1999
    ESC ALGORITHM
    Indications for implementation of IABP and LVAD
    In selected patients with myocardial infarction
    (STEMI)
    INDIKASI GUIDELINE
    IABP
    ESC
    !"#!
    ACC/AHA
    !"#%
    German/Austrian
    !"#!
    Complicated by cardiogenic shock IIb IIa
    Treatment with PCI !
    Treatment wi th fi bri nol ysi s/ wi th no
    perfusion strategy
    "
    Before transport to an interventional centre
    for PCI
    "
    LVAD
    IIb IIb
    27
    ! : dapat dipertimbangkan namun bukti masih belum jelas; ": direkomendasikan
    MECHANICAL SUPPORT
    IATROGENIC SHOCK
    Coronary occlusion
    LV compliance "
    PCWP !
    CO " or unchanged
    Redistribution of
    intravascular volume
    to lung
    Pulmonary edema
    Lower CO
    Hypotension
    Cardiogenic shock
    RV infarction
    RV RVEDP ! (>15)
    CVP !
    Shift of interventricular
    septum toward LV
    Impaired LV lling &
    systolic function due to
    changes in LV geometry

    Low SV

    Compensatory
    tachycardia
    Diuretic
    Preload "
    Intravascular volume "
    SVR "
    $ blocker
    Reynolds, 2008
    ACEi
    Nitrate
    ASSESSMENT OF CARDIOGENIC SHOCK
    Systemic hypotension
    (SBP <90 mm Hg or
    !MAP by 30 mm Hg)
    Ashen/cyanotic and cool
    skin; mottled extremities
    Rapid & faint peripheral
    pulses and may be
    irregular (if arrhythmias)
    Jugular venous
    distention, crackles in
    the lungs & peripheral
    edema
    Heart sounds usually
    distant, & may be present
    S
    3
    &S
    4
    Low pulse pressure &
    usually tachycardia
    Signs of hypoperfusion:
    altered mental status &
    !urine output
    ASSESSMENT OF CARDIOGENIC SHOCK
    Laboratory

    Elevated lactate level and decreased serum bicarbonate

    Increasing blood urea nitrogen and creatinine


    Electrocardiographic
    New or recurrent electrocardiographic evidence of ischemia or infarction
    Chest X-Ray
    New or worsening pulmonary congestion
    Echocardiographic

    Hemodynamic assessment/monitoring (left/right ventricular systolic


    function, decreased stroke volume, cardiac output/index, diastolic function,
    PCWP, PA pressure, SVR, PVR, IVC)

    Contractility

    Mechanical abnormalities (ventricular septal/free wall rupture, pericardial


    uid with tamponade)

    Valvular dysfunction (severe mitral regurgitation)


    INITIAL MANAGEMENT
    E
    M
    E
    R
    G
    E
    N
    C
    Y
    R
    O
    O
    M
    0
    min
    I
    C
    C
    U
    E
    M
    E
    R
    G
    E
    N
    C
    Y
    R
    O
    O
    M
    5
    min
    I
    C
    C
    U
    E
    M
    E
    R
    G
    E
    N
    C
    Y
    R
    O
    O
    M
    15
    min
    I
    C
    C
    U
    E
    M
    E
    R
    G
    E
    N
    C
    Y
    R
    O
    O
    M
    60
    min
    I
    C
    C
    U
    EARLY TRIAGE & MONITORING
    INITIAL RESUSCITATION
    Age: 6574, %75

    Heart rate >100 beats/ min

    Systolic BP<100 mmHg

    Proportional pulse pressure &25 mmHg (CI <2.2 L/min/m


    2
    )

    Orthopnea (PCWP >22 mmHg)

    Tachypnea (>20/min), (>30/min)

    Killip class II-IV

    Clinical symptoms of tissue hypoperfusion/hypoxia

    Arterial line and CVC

    Standard transthoracic echocardiogram (assess LV&RV


    function and mechanical complications of MI)

    Early coronary angiography in myocardial intervention


    center when signs and/or symptoms of ongoing myocardial
    ischemia (e.g. STEMI)
    INITIAL MANAGEMENT
    Start high ow O2
    Establish i.v. access
    CORRECT: hypoglycemia & hypocalcemia
    TREAT: sustaned arrhythmias: brady or tachy, Isotonic saline-uid challenge of 20-30
    ml/kg/BW over a 30 until CVP 8-12 mmHg or perfusion improves (max500 ml)
    CONSIDER: NIV mechanical ventilation for comfort (fatigue, distress) or to correct
    acidosis/ hypoxemia
    INOTROPIC SUPPORT (dobutamine and/or vasopressor support)
    E
    M
    E
    R
    G
    E
    N
    C
    Y
    R
    O
    O
    M
    0
    min
    I
    C
    C
    U
    E
    M
    E
    R
    G
    E
    N
    C
    Y
    R
    O
    O
    M
    5
    min
    I
    C
    C
    U
    E
    M
    E
    R
    G
    E
    N
    C
    Y
    R
    O
    O
    M
    15
    min
    I
    C
    C
    U
    E
    M
    E
    R
    G
    E
    N
    C
    Y
    R
    O
    O
    M
    60
    min
    I
    C
    C
    U
    EARLY TRIAGE & MONITORING
    INITIAL RESUSCITATION
    INITIAL MANAGEMENT
    Cent ral venous sat urat i on
    (ScvO
    2
    ) %70% (provided SpO
    2

    %93% and Hb level %9 g/dL)
    In persistent drug-resistant cardiogenic shock,
    consider mechanical circulatory support
    MAP % 60 mmHg
    PCWP & 18 mmHg or below
    CVP 8-12 mmHg
    Urinary ouput % 0,5 ml/hr/kgBW
    Arterial pH of 7.3-7.5
    Take Home Messages
    Cardiogenic shock is the most common cause of
    death in patients hospitalized with acute myocardial
    infarction and is associated with a poor prognosis.
    Appropriate treatment is based on a good
    understanding of the underlying pathophysiological
    mechanisms.
    Cardiogenic Shock is a treatable illness with a
    reasonable chance for full recovery.
    THANK YOU
    Cardiogenic Shock
    Mochamad Yusuf
    2013
    VASOPRESSORS AND INOTROPES
    ESC ALGORITHM
    ESC 2012
    TAKE HOME MESSAGE
    KNOW YOUR ENEMY
    TREAT UNDERLYING DISEASE
    SUPPORT HEMODYNAMICS
    BE FAST
    LEFT VENTRICULAR ASSIST DEVICES (LVAD)
    MECHANICAL SUPPORT
    MECHANICAL SUPPORT
    MECHANICAL SUPPORT
    MECHANICAL SUPPORT
    INITIAL MANAGEMENT
    IABP-SHOCK Trial
    MECHANICAL SUPPORT
    MECHANICAL SUPPORT
    IABP-SHOCK Trial II

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