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Management of cardiogenic shock

Session presentations
  • Patient characteristics. Presented by V-P Harjola (Helsinki, FI) See the slides
  • Current pathophysiological concepts. Presented by C Rapezzi (Bologna, IT) See the slides
  • Current management. Presented by J Poess (Homburg/Saar, DE) See the slides 
  • Prevention by early interventions. Presented by H Thiele (Leipzig, DE) See the slides
Heart Failure (HF)

The incidence of cardiogenic shock (CS) according to the registries is between 4-11%. The leading cause is acute coronary syndromes (ACS). The overall incidence of CS in ACS decreased from 13% to 7-8%, 2-3% on admission but mostly CS develops during hospitalization.  Comparison of the characteristic of patients with CS with those without shock admitted for ACS shows that the group with CS is older, has more comorbidities, more often presented with STEMI and after cardiac arrest. Catheterization is performed in only 57% and in-hospital revascularization in 47%.  Short term mortality in CS decreased from 70-80% in 1970 to 50-60% in the 1990s. Prof. Rapezzi stressed that CS is not simply a severe form of acute heart failure, synonymous with severe pump depression or a merely hemodynamic disease. CS is the result of acute or subacute derangements in the circulatory system with a relevant” biologic” component.

The large spectrum of causes of CS was discussed:  left ventricle vs right ventricle, delayed shock, iatrogenic shock after ACE-I, beta-blocker or diuretic therapy, bleeding/transfusion CS.

CS means the emergency indication for treatment and in ACS the indication for the intervention. Irrespective of age, each patient should be revascularized.

Hemodynamic monitoring, as usual, should be use to confirm the diagnosis and to guide therapy.  Inotropes may increase the mortality and should be reserved for patients with severe reduction of cardiac output. Dobutamine is an inotrope of choice. Levosimendan or PDE inhibitors may be considered if the effects of dobutamine are insufficient. Vasopressors may be considered when inotropes have failed. Norepinephrine is a vasopressor of choice. Catecholamines should be used at the lowest possible dose as long as necessary.

Intra aortic balloon pump (IABP) is underused in CS. In a meta-analysis of 9 trials, IABP was shown to reduce mortality in CS compared with no IABP. The results of the IABP-Schock II Trial will be presented by Professor Thiele on Monday during the Hot Line session. 600 patients were randomized to IABP or No IABP on the top of the usual interventional and pharmacological treatment.

How to treat CS in multivessel disease is still an open question. A new trial is planned by Prof. Thiele to compare the results of culprit lesion vs multivessel revascularization: the CULPRIT-SHOCK trial. There is an urgent need for more randomized control trials in CS populations.




Management of cardiogenic shock

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.