Cardiogenic Shock

Diagnosis, Treatment and Guidelines

Bagus Andi Pramono
 SHOCK= Perfusi jaringan inadekuat

Mechanisms:
Penghantaran oksigen indakeuat
Pelepasan mediator inflamasi
Perubahan mikrovaskular, aliran darah dan
hipoperfusi seluler

Manifestasi klinis:
Multiple organ failure
Hypotension
Membedakan Tipe Shock
 Etiologi
Infark miokard akut
Kegagalan fungsi ventrikel
kiri
Ruptur septum ventrikel
Ruptur korda regurgitasi
mitral severe
Ruptur dinding ventrikel
dengan tamponade
Other conditions complicating large MIs
Hemorrhage
Infection
Excess negative inotropic or
vasodilator medications
Prior valvular heart disease
Hyperglycemia/ketoacidosis
Post-cardiac arrest
Post-cardiotomy
Refractory sustained
tachyarrhythmias
Acute fulminant myocarditis
End-stage cardiomyopathy
Hypertrophic cardiomyopathy with
severe outflow obstruction
Aortic dissection with aortic
insufficiency or tamponade
Pulmonary embolu
Severe valvular heart disease -
Critical aortic or mitral stenosis,
Acute severe aortic or MR
Pathophysiology
 Clinical Findings
Pemfis : JVP meningkat, suara gallop,
rales, oliguria, edema paru akut
Hemodinamik : penurunan cardiac
output, peningkatan resistensi vaskular
sistemik, penurunan SvO2
Evaluasi inisial : hemodinamik (PA
catheter, echocardiography (non invasif),
angiografi
 4 Potential Therapies
Pressors
Intra-aortic Balloon Pump (IABP)
Fibrinolytics
Revascularization: CABG/PCI

Refractory shock: ventricular assist device,

cardiac transplantation
Kriteria Klasik untuk Diagnosis Shock Kardiogenik

1. Systemic Hypotension
Tekanan darah sistolik < 80 mmHg
2. Hipotensi Persisten
at least 30 minutes
3. Fungsi Jantung Sistolik Turun
Cardiac index < 1.8 x m/min
4. Hipoperfusi Jaringan
Oliguria, ekstremitas dingin, confusion
5. Increased Left Ventricular Filling
Pulmonary capillary wedge pressure > 18 mmHg
 SHOCK Trial
Primary and Secondary Endpoints
80
P= .027
P=.11
60 63.1%
Mortality (%)

Immediate
56.0% Revascularization
50.3%
40 Strategy
46.7%
Medical Stabilization
as an Initial Strategy
20

0
30 Days 6 months

Primary Endpoint Secondary Endpoint

Hochman et al, NEJM 1999; 341:625.
 SHOCK Trial: Age < 75
Immediate Revascularization Strategy
Medical Stabilization as an Initial Strategy

80 80 P < 0.002
P < .01

60 60 65.0%
56.8%
%
40 41.4%
40 44.9%

20 20

0 0
30 Day Mortality 6 Month Mortality

Hochman et al, NEJM 1999; 341:625.

 SHOCK Trial: Age > 75
Immediate Revascularization Strategy
Medical Stabilization as an Initial Strategy

P < 0.003
P < .01
80 80
75.0% 79.2%

60 60
53.1% 56.3%
%
40 40

20 20

0 0
30 Day Mortality 6 Month Mortality

Hochman et al, NEJM 1999; 341:625.

 ACC/AHA Guidelines for Cardiogenic Shock

Class I
1. IABP is recommended for STEMI patients when
cardiogenic shock is not quickly reversed with
pharmacological therapy. The IABP is a
stabilizing measure for angiography and prompt
revascularization.
2. Intra-arterial monitoring is recommended for the
management of STEMI patients with cardiogenic
shock.
 ACC/AHA Guidelines for Cardiogenic Shock
Class I
1. Early revascularization, either PCI or CABG, is
recommended for patients < 75 years old with ST
elevation or new LBBB who develop shock unless
further support is futile due to patients wishes or
unsuitability for further invasive care.
2. Fibrinolytic therapy should be administered to STEMI
patients with cardiogenic shock who are unsuitable for
further invasive care and do not have contraindications
for fibrinolysis.
3. Echocardiography should be used to evaluate
mechanical complications unless assessed by invasively