Der kardiogene Schock – wie stellt man die Diagnose und was muss man tun?

Abstract

Cardiogenic shock is defined by low cardiac output with consecutive organ dysfunction. Most frequently caused by an underlying myocardial infarction, patients suffer from a severely impaired prognosis with a mortality of 50 – 80 %. Patients should be diagnosed and treated immediately after admission with fluids, dobutamine, and, if necessary, norepinephrine (early goal directed therapy). The only specific treatment proven to be beneficial to date in terms of long-term prognosis is urgent revascularization. Therefore, rapid transfer to a PCI center is mandatory. Detailed information on the various treatment modalities are summarized in this article and available in the German-Austrian S3-guidelines for the treatment of cardiogenic shock (http://leitlinien.dgk.org/files/2011_Leitlinie_kardiogener_Schock.pdf).

Kernaussagen

• Häufigste Ursache eines kardiogenen Schocks ist ein großer akuter Myokardinfarkt.

• Die Mortalität von Patienten mit kardiogenem Schock liegt weiterhin bei ca. 50 – 70 %.

• Die Pathophysiologie des Schocks beinhaltet eine Spirale, bestehend aus ischämiebedingter Myokarddysfunktion und dadurch bedingtem systemischem RR-Abfall, wodurch sich wiederum die Ischämie verstärkt.

• Der Schlüssel zum therapeutischen Erfolg ist ein rasches Vorgehen mit schneller Diagnose und sofortiger Einleitung der Therapie, um Blutdruck und Herzleistung im Zielbereich zu halten. Die rasche koronare Revaskularisierung mittels PCI und Stent ist entscheidend.

• Krankenhäuser ohne direkte Angioplastie-Möglichkeit sollten den Patienten nach Stabilisierung mit IABP und Thrombolyse in ein tertiäres Behandlungszentrum überweisen.

• Weitere detaillierte Informationen zum kardiogen Schock finden sich der aktuellen S3-Leitinie: (http://leitlinien.dgk.org/files/2011_Leitlinie_kardiogener_Schock.pdf) bzw. in deren Zusammenfassung in der Zeitschrift Intensiv und Notfallmedizin.

• Literatur

• 1 Adams H, Baumann G, Gansslen A et al. Definition of shock types. Anasthesiol Intensivmed Notfallmed Schmerzther 2001; 36 (Suppl. 02) 140-143
• 2 Alexander J, Reynolds H, Stebbins A et al. Effect of tilarginine acetate in patients with acute myocardial infarction and cardiogenic shock: the TRIUMPH randomized controlled trial. JAMA 2007; 297: 1657-1666
• 3 Chen EW, Canto JG, Parsons LS et al. Relation between hospital intra-aortic balloon counterpulsation volume and mortality in acute myocardial infarction complicated by cardiogenic shock. Circulation 2003; 108: 951-957
• 4 Christoph A, Prondzinsky R, Russ M et al. Early and sustained haemodynamic improvement with levosimendan compared to intraaortic balloon counterpulsation (IABP) in cardiogenic shock complicating acute myocardial infarction. Acute Card Care 2008; 10: 49-57
• 5 Cotter G, Kaluski E, Milo O et al. LINCS: L-NAME (a NO synthase inhibitor) in the treatment of refractory cardiogenic shock: a prospective randomized study. Eur Heart J 2003; 24: 1287-1295
• 6 Cotter G, Williams SG, Vered Z et al. Role of cardiac power in heart failure. Curr Opin Cardiol
• 7 Cuffe MS, Califf RM, Adams Jr KF et al. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA 2002; 287: 1541-1547
• 8 De Backer D, Biston P, Devriendt J et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 362: 779-789
• 9 Delle Karth G, Buberl A, Geppert A et al. Hemodynamic effects of a continuous infusion of levosimendan in critically ill patients with cardiogenic shock requiring catecholamines. Acta Anaesthesiol Scand 2003; 47: 1251-1256
• 10 Field S, Kelly SM, Macklem PT. The oxygen cost of breathing in patients with cardiorespiratory disease. Am Rev Respir Dis 1982; 126: 9-13
• 11 Friedrich JO, Adhikari N, Herridge MS et al. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med 2005; 142: 510-524
• 12 Fuhrmann JT, Schmeisser A, Schulze MR et al. Levosimendan is superior to enoximone in refractory cardiogenic shock complicating acute myocardial infarction. Crit Care Med 2008; 36: 2257-2266
• 13 Geppert A, Steiner A, Zorn G et al. Multiple organ failure in patients with cardiogenic shock is associated with high plasma levels of interleukin-6. Crit Care Med 2002; 30: 1987-1994
• 14 Goldberg RJ, Gore JM, Alpert JS et al. Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. N Engl J Med 1991; 325: 1117-1122
• 15 Heer T, Zeymer U, Juenger C et al. Beneficial effects of abciximab in patients with primary percutaneous intervention for acute ST segment elevation myocardial infarction in clinical practice. Heart 2006; 92: 1484-1489
• 16 Hochman JS, Boland J, Sleeper LA et al. Current spectrum of cardiogenic shock and effect of early revascularization on mortality. Results of an International Registry. SHOCK Registry Investigators. Circulation 1995; 91: 873-881
• 17 Hochman JS, Buller CE, Sleeper LA et al. Cardiogenic shock complicating acute myocardial infarction – etiologies, management and outcome: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?. J Am Coll Cardiol 2000; 36: 1063-1070
• 18 Hochman JS, Sleeper LA, Webb JG et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA 2006; 295: 2511-2515
• 19 Hochman JS, Sleeper LA, Webb JG et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med 1999; 341: 625-634
• 20 Holmes Jr DR, Bates ER, Kleiman NS et al. Contemporary reperfusion therapy for cardiogenic shock: the GUSTO-I trial experience. The GUSTO-I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries.. J Am Coll Cardiol 1995; 26: 668-674
• 21 Jolly S, Newton G, Horlick E et al. Effect of vasopressin on hemodynamics in patients with refractory cardiogenic shock complicating acute myocardial infarction. Am J Cardiol 2005; 96: 1617-1620
• 22 Lindholm MG, Kober L, Boesgaard S et al. Cardiogenic shock complicating acute myocardial infarction; prognostic impact of early and late shock development. Eur Heart J 2003; 24: 258-265
• 23 Metra M, Nodari S, D'aloia A et al. Beta-blocker therapy influences the hemodynamic response to inotropic agents in patients with heart failure: a randomized comparison of dobutamine and enoximone before and after chronic treatment with metoprolol or carvedilol. J Am Coll Cardiol 2002; 40: 1248-1258
• 24 Prondzinsky R, Lemm H, Swyter M et al. Intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock: the prospective, randomized IABP SHOCK Trial for attenuation of multiorgan dysfunction syndrome. Crit Care Med 38: 152-160
• 25 Rassin M, Sruyah R, Kahalon A et al. "Between the fixed and the changing": examining and comparing reliability and validity of 3 sedation-agitation measuring scales. Dimens Crit Care Nurs 2007; 26: 76-82
• 26 Russ MA, Prondzinsky R, Carter JM et al. Right ventricular function in myocardial infarction complicated by cardiogenic shock: Improvement with levosimendan. Crit Care Med 2009; 37: 3017-3023
• 27 Russ MA, Prondzinsky R, Christoph A et al. Hemodynamic improvement following levosimendan treatment in patients with acute myocardial infarction and cardiogenic shock. Crit Care Med 2007; 35: 2732-2739
• 28 Sjauw KD, Engstrom AE, Vis MM et al. A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines?. Eur Heart J 2009; 30: 459-468
• 29 Slater J, Brown RJ, Antonelli TA et al. Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?. J Am Coll Cardiol 2000; 36: 1117-1122
• 30 Webb JG, Lowe AM, Sanborn TA et al. Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial. J Am Coll Cardiol 2003; 42: 1380-1386
• 31 Webb JG, Sleeper LA, Buller CE et al. Implications of the timing of onset of cardiogenic shock after acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?. J Am Coll Cardiol 2000; 36: 1084-1090
• 32 Werdan K, Ruß M, Buerke M et al. Deutsch-österreichische S3-Leitlinie "Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie". Intensivmed 2011; 48: 291-344
• 33 White HD, Assmann SF, Sanborn TA et al. Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial. Circulation 2005; 112: 1992-2001
• 34 Zion MM, Balkin J, Rosenmann D et al. Use of pulmonary artery catheters in patients with acute myocardial infarction. Analysis of experience in 5,841 patients in the SPRINT Registry. SPRINT Study Group.. Chest 1990; 98: 1331-1335