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Cardiogenic Shock

Ashley Cozart


Impairment of cardiac output due to primary cardiac disorder that results in end-organ hypoperfusion and hypoxia


  • Cardiomyopathic: myocardial infarction with LV dysfunction, exacerbation of heart failure, myocarditis, myocardial contusion, drug-induced
  • Arrhythmic: atrial tachycardias (atrial fibrillation/flutter, AVRT, AVNRT), ventricular tachycardia and fibrillation, complete heart block, second degree heart block
  • Mechanical: valvular insufficiency, valvular rupture, critical valvular stenosis, ventricular septal wall defect, ruptures ventricular wall aneurysm, atrial myxoma


  • Cold (decreased perfusion) due to reduced cardiac output (can be wet- increased PCWP OR dry normal PCWP)
  • Symptoms of volume overload + end-organ hypoperfusion (altered mental status, nausea, abdominal pain, decreased urine output)
  • Hypotension; narrow pulse pressure


  • EKG
  • Labs: CBC, CMP, BNP, troponin, lactate
  • Evidence of end organ damage: lactic acidosis, acute kidney injury, acute liver injury
  • Echocardiogram: assess EF and valves
  • LHC If ischemia (see ACS)
  • Hemodynamic monitoring via Swan-Ganz or PA catheter:
    • No benefit for general shock but does improve in-hospital mortality for those with cardiogenic shock
    • PA catheter hemodynamic profile:
      • Cardiac index \< 2.2, cardiac power \<0.6, SVR 800-1600, SVO2 \<60%
      • LV-dominant: RA (CVP) \<15, PCWP >18, PAPi >1.5 (pulmonary artery pulsatility index)
      • RV-dominant: RA >15, PCWP \<18, PAPi >1.5
      • Bi-V-dominant: RA >15, PCWP >18, PAPi >1.5
      • PAPi \< 1 indicates that patient will likely need RV support
      • CP \< 0.5 strongest independent hemodynamic correlate of mortality in CS
      • See right heart cath section for interpreting PA catheter profiles

Management (medical & mechanical circulatory support)

Medical management

Focus on optimizing preload, afterload, and contractility.

  • Preload: IV diuresis
  • Afterload: IV – nitroglycerine, nitroprusside; PO – hydralazine, isosorbide dinitrate; vasoconstricting pressors (phenylephrine, vasopressin) if needing BP support
  • Contractility - Inodilators (increase contractility, decrease afterload – milrinone, dobutamine) or inoconstrictors (increase contractility and afterload – epinephrine, norepinephrine)

Mechanical circulatory support indications

  • Shock refractory to >1 pressor
  • Shock 2/2 MI (physiology: unloads LV, increases systemic perfusion, increases myocardial perfusion, and provides hemodynamic support during PCI)

Types of mechanical circulatory support (MCS)

Intra-aortic Balloon Pump V-A ECMO Tandem Heart Impella
Dynamics Inflates during diastole, deflates during systole Blood from femoral vein is oxygenated and pumped to femoral artery

LV: blood aspirated from LA to femoral artery

RV: blood aspirate from RA to PA

Impella 2.5, 5.0 & CP: Blood aspirated from LV to aortic root

Impella RP: Blood aspirated from IVC and delivered to PA

Flow 1 LMP 4.5 LPM 4-5 LPM

2.5: 2.5 L/min

CP: 3.33 L/min

5.0: 5 L/min

RP: 4 L/min

Support LV BiV LV, RV, or BiV LV or RV (RP)

Reduces afterload

Increases stroke volume (SV)

Increases coronary perfusion

Reduces LV preload and PCWP

Increases afterload

Reduces SV

Reduces LV preload and PCWP

Improves tissue perfusion

Increases afterload

Reduces SV

Reduces LV preload and PCWP

Improves tissue perfusion

Reduces SV

Reduces preload and PCWP

Improves tissue perfusion




Arterial obstruction

Aortic rupture or dissection

Air embolism

Circuit thrombosis

LV dilation


Gas embolism

Tamponade d/t perforation


Embolism (gas or thrombus)

Arterial Shunt

Pump migration


Aortic regurg

LV perf


Daily management of MCS devices:

  • Ensure optimal placement of device with daily CXR
  • Anticoagulation (based on device)
  • Hematoma monitoring at device site
  • Check distal pulses to monitor for limb ischemia

Pearls for MCS

  • MCS devices are contraindicated in following situations: aortic regurgitation or metallic aortic valve, aortic aneurysm or dissection, severe aortic or peripheral artery disease, left ventricular or left atrial thrombi, bleeding diathesis, uncontrolled sepsis
  • ECMO is placed by the cardiac surgery team, once a patient is cannulated they will move onto the cardiac surgery team
  • Impella, tandem heart, and IABPs are placed in the cath lab
  • MCS is a bridge to recovery/definitive therapy, durable cardiac support (VAD), or transplant

Last update: 2022-05-29 04:05:22