Cardiogenic Shock The Modern Strategic Approach

The management of patients with cardiogenic shock mandates a rapid decision process and efficient delivery of care (Fig. 7). Assessment of the predictive indicators of shock should accentuate the goal of myocardial salvage in patients at risk. Early reperfusion and immediate intervention in treating recurrent ischemia may curtail myocardial injury, thereby decreasing the possibility of left ventricular power failure. Early meticulous management of hypotension or heart failure may prevent progression.

In patients with established shock, diagnostic evaluation and supportive therapy should proceed as parallel processes. Hemodynamic evaluation, echocardiography, and vasopressor therapy should be enacted promptly. Available data supports a strategy of early cardiac catheterization and revascularization. Thrombolytic therapy and balloon counterpulsation should be instituted in patients who present with shock to hospitals without revascularization facilities. Transfer to a revascularization center should follow. Single vessel obstruction can usually be approached with coronary angioplasty. Correlation of coronary anatomy and regional left ventricular function may aid decisions regarding revascularization of patients with multivessel disease. Urgent surgery should follow in patients identified with mechanical complications.

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