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Percutaneous cardiac support devices for cardiogenic shock: current indications and recommendations

2012; BMJ; Volume: 98; Issue: 16 Linguagem: Inglês

10.1136/heartjnl-2012-301963

1468-201X

Dagmar M. Ouweneel, José P.S. Henriques,

Cardiac Arrest and Resuscitation

Cardiogenic shock (CS) is a physiological state in which inadequate tissue perfusion results from cardiac dysfunction, most commonly following acute myocardial infarction. Non-ischaemic causes include myocarditis, end-stage cardiomyopathy or sustained arrhythmias. The use of reperfusion therapy has substantially reduced 30-day mortality in acute ST-segment elevation myocardial infarction (STEMI) patients.w1–w3 Currently, the optimal reperfusion therapy is timely primary percutaneous coronary intervention (PCI). The improvement in clinical outcome has been mostly observed in STEMI patients without cardiogenic shock. Despite reperfusion therapy, approximately 6–10% of STEMI patients develop cardiogenic shock during initial hospitalisation.1 ,2 w4 The large multicentre Should we Emergently Revascularise Occluded Coronaries for Cardiogenic Shock? (SHOCK) trial and registry demonstrated that early revascularisation, including PCI or coronary artery bypass grafting, in cardiogenic shock patients improves clinical outcome, but the overall 6-month mortality of cardiogenic shock patients remained 50%3 in accordance with other reports.1 w4 Despite reperfusion by primary PCI, cardiogenic shock remains the leading cause of death for hospitalised STEMI patients.1 w5 Cardiogenic shock after STEMI is mostly a consequence of decreased myocardial contractility due to the infarction, resulting in a cascade of decreased cardiac output, hypotension and decreased coronary blood flow (CBF), which will further reduce contractility and cardiac output. This vicious circle may not only lead to further myocardial ischaemia, but also to diminished organ perfusion and may ultimately result in multiple organ failure and death. Additional aggravation of the downward spiral is caused by a systemic inflammatory response and excess nitric oxide synthesis induced by the myocardial infarction, which further induces vasodilatation.2 Clinically, cardiogenic shock is characterised by hypotension and defined by a systolic blood pressure of less …