Cardiogenic Shock: Drug Therapy

Therapeutic target

  • Stabilization of circulatory conditions to counteract the development of multiple organ failure.

Therapy recommendations

  • Prompt surgical intervention for
    • Infarct-related cardiogenic shock (ICS) → percutaneous coronary intervention (PCI), usually as stent implantation [coronary revascularization is key predictor of long-term survival] (see topics of the same name below)
    • Shock-inducing pericardial tamponade/effusion, tension pneumothorax.
  • In hypovolemia (reduction in the circulating amount of blood in the bloodstream) if necessary preload increase with volume administration (crystalloid and colloid) under close control of hemodynamics; avoid volume overload!Note: Restrained volume administration in acute respiratory distress syndrome (ARDS) or severe or pre-existing heart failure.
  • Catecholamines should be used if persistent MAP (mean arterial pressure) <65 mmHg:
    • Dobutamine (β-1-agonist; inotropic) in primary pump failure; dosage: 2-20 μg/kg/min [inotropic/increase in cardiac contractility with mild vasodilatory effect; 1st-line agent].
      • Moderate hypotension (low blood pressure) to increase inotropy [inotropic agent of choice for IkS]
      • Right ventricular failure (RHV) pulmonary and systemic vasodilating as well as positive inotropicDose: onset at 2-3 µg/kg/min; dose-response: 2.5-10 µg/kg
    • Adrenaline (epinephrine), hypotension not ameliorated by dobutamine (values < 65 mmHg); dosage: 0.005-0.02 µg/kg/min [epinephrine increases cardiac output via β-1-receptor activation while mediating vasoconstriction (vasoconstriction) via α-1-receptors; greater vasoconstriction of the splanchnic area (“visceral-supplying vessels”) than with norepinephrine or dopamine]Note: Is due to overshooting organ damage and lethality reserved exclusively for resuscitation!
    • Norepinephrine in primary hypotension; dosage: norepinephrine infusion of 0.1-1.0 μg/kg/min
      • Refractory hypotension [vasopressors/substances that raise or support blood pressure; are drug of choice in IkS; norepinephrine should be used to raise blood pressure, dobutamine should be used as ionotropic support]
      • Right heart failure (RHV) [catecholamine as first choice]
    • Levosimendan may be tried if hemodynamic response to catecholamines is inadequate: 24 h infusion; dosage: 0.05-0.2 µg/kg/min [increase cardiac inotropy via Ca 2+ sensitization and afterload reduction (decrease SVR) and myocardial protection due to K + channel-mediated vasodilation]
    • Note: Dopamine is generally not indicated; there are also currently no data demonstrating that acute renal failure (ANV) or acute mesenteric ischemia (AMI) is prevented.
  • Phosphodiesterase inhibitors (phosphodiesterase-3 inhibitors) such as enoximone or milrinone may be tried if there is an inadequate response to catecholamines. [Note: in catecholamine-refractory MICS (myocardial infarction (MI) + cardiogenic shock (CS)), levosimendan is preferred over phosphodiesterase (PDE) III inhibitors] for
    • Decompensated chronic heart failure or marked beta-receptor blockade.
    • Right heart failure (RHV) positively inotropic (increasing the contractile force of the heart) and vasodilating (dilating blood vessels) without direct effects on heart rate

    Medication:

    • Milrinone: continuous infusion: dosage: 0.375-0.75 µg/kg/min.
    • Enoximone: continuous infusion: dosage: 1.25-7.5 µg/kg/minCaution: do not bolus due to a marked hypotension risk
  • Reverse failure: invasive ventilation to achieve SaO2 (arterial oxygen saturation) of 95-98%.
  • Antiarrhythmic therapy – sinus rhythm (normofrequency, regular heartbeat) with rate control optimal.
  • If necessary, afterload reduction with sodium nitroprusside.
  • Fibrinolysis (dissolution of a fibrin clot by enzyme action) should be performed within the 6-hour period in those patients with initial infarct-related cardiogenic shock.
  • Correction of electrolytes (blood salts) if necessary.
  • Ventilation: oxygen administration and generous indication of mechanical ventilationNote: In acute right heart failure (RHV), preference should be given to noninvasive ventilation!
  • Analgesia (pain relief), sedation (calming), anxiolysis (anxiety relief) – consistent monitoring and observation with a sedation scale.
  • Enteral nutrition/drinking food if swallowing is still possible (instead of parenteral nutrition) in case of hemodynamic instability
  • Pacemaker therapy for uncontrollable bradycardia (heart rate too slow: < 60 beats per minute).
  • Cardioversion for tachycardia (> 100 beats per minute); if inadequate, then start with amiodarone
  • Mechanical circulatory support (mechanical active circulatory support systems (MCS)) with cardiac assist devices in refractory cardiogenic shock) – see “Further Therapy” below.

Note: To the extent of no adequate response to initial therapy with volume and inotropics/vasopressors → extended hemodynamic monitoring to determine three parameters (preload, afterload, contractility (cardiac output)) for therapy management. Target values of hemodynamic therapy:

  • Mean arterial pressure (MAD; mean arterial pressure, MAP): 65-75 mmHg; low pressures can be tolerated with adequate diuresis (urinary excretion by the kidneys).
  • Clearance (CI; measure of renal clarification or detoxification capacity): > 2.5 l/min 1/m2 or Cardiac Power Output (CPO) > 0.6 W or Cardiac Power Index (CPI) > 0.4 W m-2
  • Diuresis: ≥ 50 ml/h
  • Lactate: < 2; lactate clearance: > 40%.

Further notes

  • Cardiogenic shock is not an indication for hypothermia. The SHOCK COOL study failed to demonstrate beneficial effects on course and prognosis.
  • In infarct-related cardiogenic shock (IACS) patients, the hemodynamic effects of intra-aortic balloon counterpulsation (IABP) are moderate.