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  • Review Article
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Management of refractory cardiogenic shock

Nature Reviews Cardiology volume 13, pages 481–492 (2016)Cite this article

Subjects

Key Points

  • Cardiogenic shock is characterized by acute hypoperfusion and end-organ dysfunction owing to reduced cardiac output, and is commonly caused by acute myocardial infarction (AMI) with left ventricular dysfunction

  • Emergent revascularization is the only therapy that has been shown to reduce mortality in patients with cardiogenic shock complicating AMI

  • Refractory cardiogenic shock can be defined as ongoing evidence of tissue hypoperfusion despite administration of adequate doses of two vasoactive medications and treatment of the underlying aetiology

  • Refractory cardiogenic shock carries a poor prognosis, with an inhospital mortality of ∼50% despite pharmacological and mechanical circulatory support

  • The use of mechanical circulatory support devices for cardiogenic shock is increasing, but there is currently no evidence showing that they improve clinical outcomes

  • Novel therapeutics and robust randomized trial data are needed to address the persistently high mortality in patients with refractory cardiogenic shock

Abstract

Cardiogenic shock is a life-threatening condition that occurs in response to reduced cardiac output in the presence of adequate intravascular volume and results in tissue hypoxia. Cardiogenic shock has several underlying aetiologies, with the most common being acute myocardial infarction (AMI). Refractory cardiogenic shock presents as persistent tissue hypoperfusion despite administration of adequate doses of two vasoactive medications and treatment of the underlying aetiology. Investigators of the SHOCK trial reported a long-term mortality benefit of emergency revascularization for shock complicating AMI. Since the publication of the SHOCK trial and subsequent guideline recommendations, the increase in community-based use of percutaneous coronary intervention for this condition has resulted in a significant decline in mortality. Despite these successes in the past 15 years, mortality still remains exceptionally high, particularly in patients with refractory cardiogenic shock. In this Review, we discuss the aetiology and pathophysiology of cardiogenic shock and summarize the data on the available therapeutics and their limitations. Although new mechanical circulatory support devices have been shown to improve haemodynamic variables in patients with shock complicating AMI, they did not improve clinical outcomes and are associated with high costs and complications.

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Figure 1: The downward spiral of refractory cardiogenic shock.
Figure 2: An analysis of potential incremental cost of shifting from using intra-aortic balloon pumps (IABP) to percutaneous left ventricular assist devices (pVAD).
Figure 3: Rapid reversal of systemic hypoperfusion with an intra-aortic balloon pump (IABP) is associated with improved prognosis.
Figure 4: Meta-analysis of randomized trials comparing the effect of percutaneous left ventricular assist devices (LVAD) versus the intra-aortic balloon pump (IABP) on 30-day mortality and haemodynamics.

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  1. Division of Cardiology, New York University–Langone Medical Center, 530 First Avenue, New York, 10016, New York, USA

    Alex Reyentovich & Maya H. Barghash

  2. Department of Medicine, Cardiovascular Clinical Research Center, 530 First Avenue, New York, 10016, New York, USA

    Judith S. Hochman

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Reyentovich, A., Barghash, M. & Hochman, J. Management of refractory cardiogenic shock. Nat Rev Cardiol 13, 481–492 (2016). https://doi.org/10.1038/nrcardio.2016.96

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