Cardiogenic Shock and Pulmonary Edema
Weekly Recap 21
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Chapter 298: Cardiogenic Shock and Pulmonary Edema
Life-threatening conditions that require treatment and are medical emergencies:
Cardiogenic shock (CS)
Pulmonary edema
Cardiogenic Shock (CS)
Is a low cardiac output state resulting in:
Life-threatening end-organ hypoperfusion
Hypoxia
Hypoperfusion of vital organs and extremities
Is the clinical hallmark of cardiogenic shock
Characteristic Clinical Presentation of Cardiogenic Shock
Persistent hypotension (<90mmHg systolic blood pressure) that is UNRESPONSIVE to volume replacement +
Clinical features of peripheral hypoperfusion such as:
Elevated arterial lactate (>2mmol/L)
Vasopressors and Inotropes
Dobutamine
When given at LOW doses (2.5 ug/kg/min) has a:
Positive inotropic action
Minimal positive chronotropic activity.
When given at HIGHER doses: have a moderate chonotropic activity
Dopamine
When given at LOW doses: stimulate renal dopaminergic receptors
When given at HIGHER doses: stimulate first the beta-adrenergic receptors then stimulates the alpha-adrenergic receptors
Norepinephrine
Is the first line vasopressor based on RCT compared to dopamine
Management of Pulmonary Edema: NITRATES
Sublingual nitroglycerin (0.4 mg x3 every 5 minutes)
Is the first-line therapy for acute cardiogenic pulmonary edema
IV nitroglycerin at 5-10 ug/min
Is given to patients with persistent pulmonary edema in the absence of hypotension
IV nitroprusside (0.1-5 ug/kg per minute)
Is given to patients with pulmonary edema with hypertension
Now Let’s Dive into: SHOCK Trial
Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial.
(Reference: Menon, V., & Fincke, R. (2003). Cardiogenic Shock: A Summary of the Randomized SHOCK Trial. Congestive Heart Failure, 9(1), 35–39. https://doi.org/10.1111/j.1751-7133.2003.tb00020.x9)
Published: January-February, 2003
Population:
Adult men and women with predominant left ventricular failure following a myocardial infarction.
Ages Eligible for Study: 18 years to 75 years
Intervention:
Emergency revascularization by either coronary artery bypass grafting or angioplasty within 6 hours of randomization.
Control:
Initial medical stabilization consisting of thrombolytics.
Patients assigned to initial medical stabilization can undergo delayed revascularization at a minimum of 54 hours post-randomization.
Primary Outcome:
Mortality from all causes at 30 days
Method:
Randomized, multicenter, Phase III, controlled clinical trial.
Results:
Overall survival at 30 days did not differ significantly between the emergency revascularization and initial medical stabilization groups.
However, at the 6 month and 12-month follow-up, there was a significant survival benefit with early revascularization. The benefit appeared to be greatest for those:
Less than 75 years of age
Conclusion:
Based on the data gathered in the SHOCK trial, the American College of Cardiology/American Heart Association recommend emergency revascularization for patients younger than 75 years with cardiogenic shock.
Stay Tuned For Next Week’s Topic
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