Chapter 12

The Dynamics of Cardiogenic Shock: Pathophysiology & Therapeutic Approaches
Contributor
Dr Srivats Ramamoorthy
Assistant Professor
Department of Critical Care Medicine
King George Mesdical University (KGMU),
Lucknow, India
What is cardiogenic shock?

 It is defined as primary cardiac dysfunction leading to organ hypoperfusion and
Hypoxemia
 Clinically it presents as hypotension refractory to volume resuscitation with
features of systemic hypoperfusion requiring pharmacological or mechanical
intervention.
 Acute myocardial infarction is the commonest cause of cardiogenic shock.
 Various definition are available to classify a patient as cardiogenic shock.
 Cardiogenic shock - SBP <90 mm Hg for ≥30 minutes + signs of hypoperfusion
(cold clammy skin, low urine output) + low cardiac output (Cardiac index<
2.2l/min/m2)
What are the common causes of cardiogenic shock?
 Left ventricular failure

o Acute myocardial infarction
o Hypertrophic obstructive cardiomyopathy
o Myocarditis
o Myocardial contusion
o Peripartum cardiomyopathy
o Septic cardiomyopathy
o Stress cardiomyopathy
 Right ventricular failure

o Acute myocardial infarction
o Pulmonary embolism
o Pulmonary hypertension
 Arrhythmia
o Atrial fibrillation
o Ventricular tachycardia
o Bradycardia or heart block
Write-ups are compiled for the personal use only. PLEASE DO NOT CIRCULATE Page 1
 Valvular or mechanical dysfunction

o Aortic regurgitation—acute bacterial endocarditis
o Mechanical valve dysfunction or thrombosis
o Mitral regurgitation—myocardial ischemia or infarction
o Progressive mitral stenosis
o Progressive aortic stenosis
What is the new classification of cardiogenic shock?

 The Society for Cardiovascular Angiography and Intervention (SCAI) recently
proposed a new classification for cardiogenic shock into five stages (A–E) of
increasing severity based on clinical, biological, and hemodynamic signs
 This helps in easier bedside evaluation, prognostication, and treatment
optimization of patients with CS
Stage Description Physical Biochemical Hemodynamics

exam/bedside markers
findings
A A patient who is  Normal JVP  Normal Normotensive
At risk not currently  Lung sounds labs SBP≥100
experiencing clear  Normal • Cardiac index
signs or  Warm renal ≥2.5
symptoms of  Strong distal function • CVP <10
CS but is at risk pulses  Normal
for its  Normal lactic acid
development. mentation
E.g., patients
with large acute
myocardial
infarction.
B A patient who  Elevated  Normal SBP <90 OR
Beginning has clinical JVP lactate MAP <60 OR
CS evidence of  Rales in lung  Minimal >30 mmHg drop
relative fields renal from baseline
hypotension or  Warm function Pulse ≥100
tachycardia  Strong distal impairment • Cardiac index
without pulses  Elevated ≥2.2
hypoperfusion  Normal BNP
mentation
C A patient that May Include May Include May Include
Classic CS manifests with Any of: Any of: Any of:
hypoperfusion  Looks unwell  Lactate ≥2 SBP <90 OR
that requires  Volume  Creatinine MAP <60 OR
intervention overload doubling >30 mmHg drop
(inotrope,  Extensive OR >50% from baseline
pressor or rales drop in AND
mechanical  Killip class 3 GFR drugs/device
support, or 4  Increased used to maintain
including  Cold, LFTs BP above these
ECMO) beyond clammy  Elevated targets

volume  Acute BNP Hemodynamics
resuscitation to alteration in • cardiac index
restore mental status <2.2
perfusion.  Urine output • PCWP >15
<30 mL/h
D A patient that is Any of stage C Any of Stage Any of Stage C
Deteriorating like category C C AND: AND:
/ doom but is getting Deteriorating Requiring
worse. They multiple
have failed to pressors OR
respond to mechanical
initial circulatory
interventions. support devices
to maintain
perfusion
E A patient that is Near pH ≤7.2 No SBP without

Extremis experiencing Pulselessness Lactate ≥5 resuscitation
cardiac arrest Cardiac collapse PEA or
with ongoing Mechanical refractory VT/VF
CPR and/or ventilation Hypotension
ECMO, being Defibrillator used despite maximal
supported by support
multiple
interventions.
How do you evaluate a patient with cardiogenic shock?

 ECG
 Should be ordered within 10 minutes of presentation

 ECG findings in ACS are divided into 3 groups: ST‐segment elevation, ST‐
segment depression, and non–ST‐segment deviation
 ST‐segment elevation in ≥2 contiguous leads – urgent reperfusion is required
 ST‐segment depression ±T wave inversions: aggressive medical therapy and
evaluate immediately for early coronary angiography
 N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP):

 Elevated during an acute decompensation of heart failure and in ACS
 Echocardiography
 Look for ventricular size, contractility, regional wall motion abnormalities,
valvular abnormalities
How do you manage a patient with cardiogenic shock?
 Manage with VIP rule.
Ventilate (oxygen administration

± mechanical ventilation)
However, the sequence could be
Infuse (fluid resuscitation) individualised as per the type of
shock and its severity
Pump (administration of
vasoactive agents)
 Ventilation and Oxygenation:

 Use pulse oximeter to monitor saturation. Target SpO2 >90%
 Non-invasive ventilation/ CPAP can be used initially to support dyspnoeic
patients
 Intravenous fluids:
 Fluid administration should be cautious as overzealous administration can
lead to pulmonary oedema.
 Monitored fluid bolus (250ml) can be given to hypovolemic patients.
 Vasopressor Support
 Vasopressors should be titrated to achieve a MAP target of >65 mm Hg.
 Vasopressin is preferred in right sided heart failure

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The Dynamics of Cardiogenic Shock: Pathophysiology & Therapeutic Approaches

What is cardiogenic shock?

What are the common causes of cardiogenic shock?

 Left ventricular failure

 Right ventricular failure

 Valvular or mechanical dysfunction

What is the new classification of cardiogenic shock?

Stage Description Physical Biochemical Hemodynamics

ECMO) beyond clammy  Elevated targets

E A patient that is Near pH ≤7.2 No SBP without

How do you evaluate a patient with cardiogenic shock?

 Should be ordered within 10 minutes of presentation

 N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP):

How do you manage a patient with cardiogenic shock?

 Manage with VIP rule.

Ventilate (oxygen administration

 Ventilation and Oxygenation:

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