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Peripheral Perfusion ↓ Hypoxemia LVEDP ↑Lung edema Hypotension Coronary perfusion ↓ Vasoconstriction Fluid retention Progressive LV-Dysfunction Death Ischemia... Peripheral Perfusion ↓D

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DISSECTION TENSION

PNEUMOTHORA

X

CARDIOMYOPATHY

Ischaemic Non-ischaemic (e.g drug toxicity, stress induced)

Peripheral Perfusion ↓ Hypoxemia

LVEDP ↑Lung edema

Hypotension

Coronary perfusion ↓

Vasoconstriction Fluid retention

Progressive LV-Dysfunction

Death Ischemia

Peripheral Perfusion ↓

Death

Hypoxemia

LVEDP ↑Lung edema

Vasoconstriction Fluid retention

Hypotension

Coronary perfusion ↓

SIRS

eNOS iNOS

NO ↑Peroxynitrite ↑IL-6 ↑TNF-α ↑

SVR ↓Pro-Inflammation Catecholamine sensitivity ↓

Contractility↓

Progressive LV-Dysfunction Ischemia

Peripheral Perfusion ↓

Death

Hypoxemia

LVEDP ↑Lung edema Cardiac Output ↓

Stroke Volume ↓

Vasoconstriction Fluid retention

Hypotension

Coronary perfusion ↓

SIRS

eNOS iNOS

NO ↑Peroxynitrite ↑IL-6 ↑TNF-α ↑

SVR ↓Pro-Inflammation Catecholamine sensitivity ↓

Contractility↓

Progressive LV-Dysfunction Ischemia

TandemHeart percutaneous LVAD

CARDIOGENIC SHOCK:

TR EATMENT

Me chanical circulatory support

Extracorporeal membrane oxygenation

Cove ME Critical Care 2010;14:235-46

Peura J et al Circulation 2012;126:2648-2667

AHA Scientific Statement Recommendations for the Use of Mechanical Circulatory Support: Device Strategies and Patient Selection:

5 A Urgent nondurable MCS is reasonable in hemodynamically compromised HF

patients with endorgan dysfunction and/or relative contraindications to heart

transplantation/durable MCS that are expected to improve with time and restoration

of an improved hemodynamic profile (Class IIa; Level of Evidence C)

B These patients should be referred to a center with expertise in the management

of durable MCS and patients with advanced HF (Class I; Level of Evidence C)

Peura J et al Circulation 2012;126:2648-2667

AHA Scientific Statement Recommendations for the Use of Mechanical Circulatory Support: Device Strategies and Patient Selection:

CARDIOGENIC SHOCK: DIAGNOSTIC AND TREATMENT CONCLUSIONS

•Diagnosis of CS (What) can be done without excessive difficulty using clinical and

hemodynamic criteria

•Identification of the main causal mechanism (Why) is key to guide therapy

•Reperfusion / revascularization in ACS-related cardiogenic shock

•Steroids in giant cell myocarditis

•Repair of valve disease, mechanical complications, tamponade, arrhythmias…

•Circulatory support is needed in a majority of patients

Pascal V, Zeymer U Cardiogenoc Shock ACCA Clnical Decison-making Toolkt

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