Causes of cardiac shock. Cardiogenic shock (R57.0)

Cardiogenic shock(KS) represents critical condition microcirculation of tissues against the background of inadequate cardiac output, caused by a decrease contractility heart muscle.

The main mechanisms of CABG come down to a decrease in cardiac output, peripheral vasospasm, a decrease in BCC - the volume of circulating blood, a violation capillary blood flow and intravascular coagulation. Most often, CABG is a fatal complication of myocardial infarction.

In accordance with the classification of Academician E.I. Chazov, there are several types of cardiogenic shock, differing in the cause of occurrence, clinical features and treatment of the condition:

KS true;
KS artmic;
CS reflex;
KS is reactive.

Reflex form of CS occurs against the background of altitude pain syndrome and is explained by reflex paresis of blood vessels with subsequent stagnation of blood in them and leakage of plasma into the intercellular tissue space. The result of a decrease in blood flow to the heart muscle is a decrease in heart beats and a drop in pressure. This form of CABG often occurs in cases of posterior wall myocardial infarction.

True KS has as its basis a sharp decline contractility left ventricle, leading to a decrease in its minute volume (MV). The most serious circulatory disorders that occur with true CABG quickly lead to changes in all organs and tissues and are accompanied by anuria.

Arrhythmic form CABG is diagnosed in cases where a clear connection between the disorder is recorded peripheral microcirculation and decline in pressure with disturbances heart rate and conductivity. Typically with restoration normal rhythm manages to relieve symptoms of shock.

Areactive form CABG is confirmed by the absence of a vascular response to the administration of even large doses norepinephrine. This form of shock is the most resistant to therapeutic effects and in most cases ends in death.

Causes

There are several etiological factors development of CS. The following clinical situations most often lead to it:

disorders intracardiac hemodynamics mechanical origin (rupture of the valve or chordae tendineae, malformations, neoplasms);
decreased pumping function of the heart due to left ventricular failure (sepsis, pancarditis, cardiomyopathy, myocardial infarction);
arrhythmogenic pathology (atrioventricular blockade, brady- and tachyarrhythmias);
insufficient filling of the heart chambers during diastole (with pericardial tamponade);
autoimmune rejection (heart transplantation);
postoperative complications (damage or rupture of the artificial heart valve);
thromboembolism of the pulmonary arteries.

In 60-95% of cases, CABG aggravates the course of MI, manifesting itself against the background of a critical decline in the pumping function of the left ventricle.

Risk factors that increase the likelihood of developing shock states, are:

extensive MI involving more than 40% of the anterior wall surface;
severe ischemia of the areas of the heart surrounding the necrosis zone;
the presence of old scar changes with repeated MI;
critical decrease in the functional capacity of the left ventricle (less than 40%);
age of the patient (50 years or more);
damage to the intracardiac papillary muscles due to their necrosis;
integrity violations interventricular septum;
right ventricular myocardial infarction;
diabetes mellitus accompanying myocardial infarction.

Cardiogenic shock most often results from myocardial infarction. And rehabilitation measures are described in detail in the article.

What's happened arrhythmogenic shock and how to treat it, read.

The most dangerous complication pancreatitis is a pancreatogenic shock, which in almost half of the cases leads to the death of the patient. In this topic, we will look at the symptoms and treatment methods for this condition.

Symptoms

The specificity of complaints of patients with CABG is associated with the nature of the underlying pathology. As a rule, patients are concerned about:

pain in the heart area (behind the breastbone);
palpitations and interruptions in heart function;
weakness;
dizziness;
dyspnea;
decrease in the amount of urine excreted (oligo-, anuria);
cold extremities;
increased sweating;
feeling of fear.

An objective examination of a patient in CABG status reveals symptoms of extreme severity of his condition. In the initial stage, as a rule, it is expressed psychomotor agitation, which soon gives way to lethargy and adynamia. Consciousness gradually fades along with the loss of interest in the environment, which indicates an increase in hypoxic processes in the brain.

Skin that is cold to palpation is pale, with pronounced cyanosis, and covered with sweat. Ripple radial arteries characterized by weak filling and tension, up to a thread-like pulse or its absence. Typically, the systolic level blood pressure below 80 mmHg, but in some cases it can rise to 90 and above (mainly in the presence of anamnestic arterial hypertension).

Typical signs for CABG are a critical decrease in the pulse wave (from 30 to 10 mm Hg) and pronounced dullness of heart sounds during cardiac auscultation, gallop rhythm and systolic murmur. IN terminal states tones are not audible, so determining blood pressure by auscultation becomes impossible. On the part of the lungs, tachypnea and a shallow type of breathing are observed, which in the terminal stages acquires an aperiodic type (Cheyne-Stokes). The presence of moist rales indicates the development of pulmonary edema against the background of stagnation in the pulmonary circulation.

Prognostically unfavorable symptom with CABG, a decrease in diuresis of less than 20 ml of urine excreted per hour is considered to indicate an extreme degree of microcirculation impairment in the kidneys.

Mechanisms of occurrence

The main pathogenetic mechanisms that trigger the chain pathological processes with CABG, are the loss of the bulk of the myocardium due to occlusion of the main arteries supplying the heart, leading to multiple organ failure, and in some cases, the death of the patient.

Against the background of hypotension, which develops as a result of necrosis of the heart muscle, a syndrome of hypoperfusion of the surviving areas of the myocardium develops, followed by a deterioration in the contractility of the ventricles of the heart.

Once the loss of non-functioning myocardial mass reaches 40% of the volume of the left ventricle, irreversible consequences KSH.

Compensatory reactions from the nervous and endocrine systems V initial stages CABGs are adaptive in nature and are aimed at increasing cardiac output. Subsequently, an increase in heart rate leads to an increase in oxygen consumption by the myocardium and reflex vascular spasm. This is accompanied by the accumulation of under-oxidized products in tissues, the development of metabolic acidosis and tissue hypoxia.

In addition, against the background of damage to the vascular endothelium, significant retention of fluid and sodium occurs in the body.

The resulting cardiac arrhythmias only worsen cardiac function and in some cases lead to the death of the patient due to multiple organ failure.

Diagnosis of cardiogenic shock

Since KS is clinical syndrome, its diagnosis includes the presence of a set of symptoms characteristic of hypoperfusion individual organs and the body as a whole:

arterial hypotension (less than 80 mm Hg);
reduction pulse pressure(less than 20 mmHg);
decreased urine output (anuria or oliguria less than 20 ml per hour);
lethargy and other disturbances of consciousness;
symptoms of microcirculation crisis (marbled, pale skin color, cold extremities, acrocyanosis);
signs of metabolic acidosis.

The absence of specific symptoms pathognomonic for CS makes possible staging diagnosis of cardiogenic shock solely on the basis of a combination of several clinical symptoms. In this case, one should take into account the variability of the signs of CS in each case, depending on the main diagnosis against which the shock developed.

Acute myocardial infarction of the anterior wall of the left ventricle

Objectification of hemodynamic and other disorders during CABG is achieved using:

chest radiography;
coronary angiography;
direct determination of cardiac output;
measuring pressure in the cavities of the heart;
echocardiography;
hemodynamic monitoring.

Emergency care for cardiogenic shock - algorithm

Successful treatment of any form of CABG begins with effective pain relief.

Taking into account the hypotensive effect narcotic analgesics, their prescription is combined with drugs from the sympathomimetic group (mesaton).

Cardiac bradycardia is an indication for intravenous administration atropine.

With reflex CABG, the patient's legs are elevated to increase the volume of blood flowing to the heart. In the absence of consciousness, tracheal intubation is indicated. Lidocaine is used to prevent cardiac arrhythmias. With the help of oxygen therapy (through maxa or a catheter), they achieve improved oxygen supply to tissues. Ventricular fibrillation is a direct indication for defibrillation.

Treatment

Complex therapeutic activities to relieve coronary artery bypass consists of:

general measures (analgesics, thrombolytics, oxygenation, hemodynamic monitoring);
infusion therapy (in the absence of contraindications);
vasodilators;
medications with inotropic action (improving myocardial contractility);
electropulse therapy - to eliminate heart rhythm disturbances;
electrocardiostimulation - for conduction disorders.

In addition, instrumental methods for the treatment of CABG include balloon counterpulsation inside the aorta. For ruptures of the interventricular septum, it is indicated surgical treatment(also - with ruptures or dysfunction of the papillary muscles).

Prognosis and life chances

The prognosis for CABG is very serious and is largely determined by the degree of myocardial damage, the timeliness of diagnosis and the adequacy of treatment measures.

The areactive form of CS is considered prognostically unfavorable.

When adequate reaction on therapeutic effect and an increase in blood pressure, a favorable outcome is possible.

However, in a number of cases clinical picture may be reversed. Severe forms CABG in 70% of cases leads to fatal outcome during the first hours and days of illness.

Video on the topic

One of the most dangerous diseases is cardiogenic shock, the symptoms of which cannot always be recognized in time. This leads to the patient dying suddenly, since they do not have time to provide him with ambulance, not to mention treatment. To recognize the first signs of this terrible disease, it is necessary to become familiar with the course of the disease and the characteristics of the symptoms of shock.

Symptoms of cardiogenic shock

The main signs of cardiogenic shock are characteristically expressed, they are difficult to confuse with others, especially when the person has previously had heart problems. The sequence of all changes in the body during such a disease, i.e., the mechanism of cardiogenic shock, can be roughly represented as follows:

Systolic output is greatly reduced, and a cascade of compensatory and adaptive mechanisms is observed.
A generalized narrowing of arterial and venous vessels occurs.
A generalized spasm of arterioles is observed, as a result of which peripheral resistance appears and centralization of blood flow.
The volume of circulating blood increases, this puts additional serious stress on the heart muscle and on the left stomach, which the organ can no longer cope with.
The development of cardiac left ventricular failure appears, diastolic pressure rises.
The microcirculation pool undergoes severe disturbances.

The symptoms of cardiogenic shock do not end there. The following processes are possible:

depletion of the capillary bed;
the appearance of metabolic acidosis;
decreased blood filling coronary arteries;
necrobiotic, dystrophic, necrotic phenomena in organs, tissues (usually the liver, kidneys, skin);
increase in hematocrit level, i.e. the relationship between red blood and blood plasma;
increasing capillary permeability.

All these disorders cause the appearance of individual foci of ischemia. The plasma output gradually decreases. The process is developing rapidly, it is difficult to stop it in time. Gradually, the disturbances affect the entire body, the process spreads like a fire. Edema forms in the lungs, as well as in the brain area. Multiple foci of internal hemorrhages appear.

This development mechanism ultimately leads to the death of the patient, since the course is rapid, and it is almost impossible to determine the symptoms in time. It often happens that a relatively healthy outwardly person simply falls on the street and dies within a few hours, no help helps him. This is complicated by the fact that most passers-by simply do not notice, thinking that the patient is drunk.

Diagnosis of cardiogenic shock

The peculiarity of diagnostics is that the doctor does not have much time to make a correct diagnosis. Therefore, the so-called primary signs, i.e. objective data. Among them it is necessary to highlight:

a decrease in body temperature, along with the appearance of sticky cold sweat;
cyanosis, so-called marble leather, too much paleness;
difficult, superficial or rapid breathing, especially against the background of a drop in blood pressure;
rapid pulse, tachycardia, low filling, thread-like pulse or cannot be felt at all;
systolic pressure is greatly reduced, does not increase from 60 mm Hg. Art. often not determined at all;
when taking an ECG, a picture of MI is observed;
the tones are muffled, it is rarely possible to listen to the protodiastolic rhythm, III tone;
renal function is impaired, anuria and decreased diuresis appear;
There is pain in the heart area.

Symptoms may vary from patient to patient, so diagnosis can only be made by experienced doctor. Additionally, ultrasound, ECG and other diagnostics may be prescribed, which will help to see the picture of the disease in a more expanded manner. The measures do not take much time, but they are often carried out against the backdrop of therapeutic measures, since even a minute of delay can cost the patient his life. If possible, some types of studies are performed directly in the ambulance on the way to the hospital.

First aid for cardiogenic shock

It is not always possible to get to the clinic in a condition such as cardiac shock on time. That is why close attention must be paid to first aid. For it to be effective, you need to have a good understanding of the symptoms. It is important to remember that cardiogenic shock can occur anywhere and at any time. Many people make the mistake of mistaking a person who has fallen on the street for a drunk. In fact, his life could have been saved if not for the indifference and delusions of those around him. Yours Negative influence Ignorance of the basics of first aid for heart diseases also contributes, because even correctly performed artificial respiration and cardiac massage could save lives.

What you need to know about first aid? Initially, you need to pay attention to the following signs:

sticky cold sweat, covering the skin;
pale complexion, almost bluish;
hypothermia, i.e. a sharp decrease in body temperature;
lack of reaction to surrounding events;
your blood pressure drops significantly (usually only a health care professional or someone with a portable blood pressure measuring device can detect this).

In case of cardiogenic shock, it is necessary to perform the following set of actions:

A person's legs are raised approximately 15 degrees upward.
The patient needs to ensure an influx fresh air, why does he receive oxygen (in the intensive care unit) or does he need to open the windows, unbutton collars that are too tight, and ensure the flow of oxygen.
When the patient is unconscious, tracheal intubation is required to ensure the necessary breathing.
Already carried out in hospital settings special measures, for example, if there are no contraindications, drugs such as prednisolone, thrombolytics, anticoagulants are administered (contraindications are pulmonary edema, swelling of the veins in the neck).
Vasopressors are administered to maintain blood pressure at least at a minimum level.
Arrhythmia requires relief. For tachycardia, electric pulse therapy is used, for bradyarthria, special accelerating cardiac pacing is used, and for fibrillation, ventricular defibrillation is used. If there is asystole, indirect massage is performed.

Forecasts for the development of the disease

Even Clinical signs were recognized in time, the prognosis for this disease is not the best.

If the shock is short-lived and general state managed to stabilize, thrombosis develops against its background large vessels, infarctions of organs such as the spleen, lungs, necrosis skin, hemorrhages.

Much depends on how much the blood pressure has dropped and what the signs of disorders are. peripheral systems, general reaction body for treatment. There's no such thing as mild degree cardiogenic shock, such a disease is always serious. Many doctors advise against deluding yourself too much about the diagnosis of moderate severity, since the condition is also complex. It is important to ensure that it does not develop side effects, the condition did not begin to deteriorate. That is why it is recommended that the patient spend time under constant supervision.

The severe form, the manifestations of which are more serious, leaves almost no chance of survival, even if emergency assistance is provided in time. The vast majority of patients, approximately 70%, die within the first 24 hours, but most often mortality occurs in the first 4-6 hours after shock. Some patients can live for a couple of days, but rarely anyone survives for more than 3 days. According to statistics, only ten patients out of a hundred manage to survive after shock, but their condition cannot be called normal or healthy. Often such patients soon die from heart failure.

There are quite a few signs of cardiogenic shock, but all of them together create a fairly characteristic picture that allows us to diagnose accurate diagnosis. Even a common person can recognize such signs and then provide prompt emergency assistance until a doctor arrives. Exactly emergency measures are vital for the salvation of man.

Cardiogenic shock

Protocol code: SP-010

ICD codes-10:

R57.0 Cardiogenic shock

I50.0 Congestive heart failure

I50.1 Left ventricular failure

I50.9 Heart failure, unspecified

I51.1 Rupture of chordae tendons, not elsewhere classified

I51.2 Rupture of papillary muscle, not elsewhere classified

Definition: Cardiogenic shock– extreme degree of left ventricular failure

pain, characterized by a sharp decrease in myocardial contractility (fall

shock and minute emission), which is not compensated by an increase in vascular

resistance and leads to inadequate blood supply to all organs and tissues,

First of all, vital organs. When a critical amount of myocardium is left-

the third ventricle is damaged, pump failure can be recognized clinically

as pulmonary insufficiency or as systemic hypotension, or both have minor

a hundred at the same time. With severe pumping insufficiency, pulmonary edema may develop.

to their. The combination of hypotension with pump failure and pulmonary edema is known as

cardiogenic shock. Mortality ranges from 70 to 95%.

Classification with the flow:

True cardiogenic.

lecture and arrhythmic shocks, which have a different genesis.

Risk factors:

1. Extensive transmural myocardial infarction

2. Repeated myocardial infarctions, especially heart attacks with rhythm disturbances and conduction

3. Zone of necrosis equal to or greater than 40% of the mass of the left ventricular myocardium

4. Decline in myocardial contractile function

5. Decrease in the pumping function of the heart as a result of the remodeling process,

starting in the first hours and days after the onset of acute coronary occlusion

6. Cardiac tamponade

Diagnostic criteria:

True cardiogenic shock

The patient complains of severe general weakness, dizziness, “fog before

eyes”, palpitations, a feeling of interruptions in the heart area, chest pain, suffocation.

1. Symptoms of peripheral circulatory failure:

Gray cyanosis or pale cyanotic, “marbled”, moist skin

Acrocyanosis

Collapsed veins

Cold hands and feet

Nail bed sample for more than 2 s (decreased peripheral blood flow velocity)

2. Impaired consciousness: lethargy, confusion, less often - agitation

3. Oliguria (decrease in diuresis less than 20 mm/hour, with severe course- anuria)

4. Decrease in systolic blood pressure to less than 90 – 80 mm Hg.

5. Decrease in pulse blood pressure to 20 mm Hg. and below.

Percussion: expansion of the left border of the heart; on auscultation, the heart sounds are deep

chie, arrhythmias, tachycardias, protodiastolic gallop rhythm (pathognomonic symptom

severe left ventricular failure).

Breathing is shallow and rapid.

The most severe course of cardiogenic shock is characterized by the development of cardiac

acute asthma and pulmonary edema. Choking appears, breathing is bubbling, coughing with

discharge of pink, frothy sputum. Percussion of the lungs reveals dullness

percussion sound in the lower sections. Here crepitus, fine tufts are also heard.

loud wheezes. As alveolar edema progresses, wheezing is heard more

more than 50% of the lung surface.

The diagnosis is based on identifying a decrease in systolic blood pressure

lower than 90 mmHg, clinical signs of hypoperfusion (oliguria, mental dullness

captivity, pallor, sweating, tachycardia) and pulmonary failure.

A . Reflex shock (pain collapse) develops in the first hours of the disease, in

a period of severe pain in the heart region due to a reflex drop in the general peripheral

ical vascular resistance.

Systolic blood pressure is about 70-80 mm Hg.

Peripheral circulatory failure - pallor, cold sweat

Bradycardia is a pathognomonic symptom of this form of shock

The duration of hypotension does not exceed 1–2 hours, the symptoms of shock disappear spontaneously.

alone or after pain relief

Develops with limited myocardial infarction of the posteroinferior sections

Characterized by extrasystoles, atrioventricular block, rhythm from the AV junction

Clinic of reflex cardiogenic shock corresponds to I degree of severity

B . Arrhythmic shock

1. Tachysystolic (tachyarrhythmic variant) cardiogenic shock

More often develops in the first hours (less often – days of illness) with paroxysmal

ventricular tachycardia, also with supraventricular tachycardia, paroxysmal

atrial fibrillation and atrial flutter. The general condition of the patient is serious.

All clinical signs of shock are expressed:

Significant hypotension

Symptoms of peripheral circulatory failure

Oligoanuria

30% of patients develop severe acute left ventricular failure

Complications - ventricular fibrillation, thromboembolism in vital organs

Relapses of paroxysmal tachycardias, expansion of the necrosis zone, development of car-

diogenic shock

2. Bradysystolic(bradyarrhythmic variant) cardiogenic shock

Develops with complete atrioventricular block with 2:1, 3:1, medical

idioventricular and nodal rhythms, Frederick's syndrome (a combination of complete

atrioventricular block with atrial fibrillation). Bradysystolic cardio-

gene shock is observed in the first hours of development of extensive and transmural infarction

that myocardium

The shock is severe

Mortality reaches 60% or more

Causes of death: severe left ventricular failure, sudden asystto-

heart failure, ventricular fibrillation

There are 3 degrees of severity of cardiogenic shock depending on the severity

clinical manifestations, hemodynamic parameters, response to ongoing

Events:

1. First degree:

Duration no more than 3-5 hours

Systolic blood pressure 90 -81 mm Hg

Pulse blood pressure 30 - 25 mm Hg

Symptoms of shock are mild

Heart failure is absent or mild

Rapid sustained pressor response to therapeutic measures

2. Second degree:

duration 5 – 10 hours

Systolic blood pressure 80 – 61 mm Hg,

Pulse blood pressure 20 – 15 mm Hg

Symptoms of shock are severe

Severe symptoms of acute left ventricular failure

Slow, unstable pressor response to therapeutic measures

3. Third degree:

More than 10 hours

Systolic blood pressure less than 60 mm Hg, may fall to 0

Pulse blood pressure less than 15 mm Hg

The course of shock is extremely severe

Severe heart failure, severe pulmonary edema,

There is no pressor reaction to treatment, an areactive state develops

List of basic diagnostic measures:

ECG diagnostics

List of additional diagnostic measures:

CVP level measurement (for resuscitation teams)

Tactics of rendering medical care :

For reflex shock, the main treatment measure is quick and complete

anesthesia.

In case of arrhythmic shock, cardioversion or

cardiac stimulation.

In case of shock associated with myocardial rupture, only emergency surgery is effective.

logical intervention.

Treatment program for cardiogenic shock

1.General activities

1.1. Anesthesia

1.2. Oxygen therapy

1.3. Thrombolytic therapy

1.4. Heart rate correction, hemodynamic monitoring

2. Intravenous fluid administration

3. Decrease in peripheral vascular resistance

4. Increased myocardial contractility

5. Intra-aortic balloon counterpulsation

6. Surgical treatment.

Emergency treatment is carried out in stages, quickly moving to the next stage

if the previous one is ineffective.

1. In the absence of pronounced congestion in the lungs:

Lay the patient down with the lower limbs elevated at an angle of 20 degrees;

Carry out oxygen therapy;

Pain relief – morphine 2 – 5 mg IV, again after 30 minutes or fentanyl 1-2 ml

0.005% (0.05 - 0.1 mg with droperidol 2 ml 0.25% IV diazepam 3-5 mg for psychomotor

excitement;

Thrombolytics according to indications;

Heparin 5000 units intravenously;

Correct heart rate (paroxysmal tachycardia with heart rate more than 150 per 1

min – absolute indication for cardioversion)

2. In the absence of pronounced congestion in the lungs and signs of increased central venous pressure:

200 ml 0.9; sodium chloride intravenously over 10 minutes, monitoring blood pressure, central venous pressure, respiratory rate,

auscultatory picture of the lungs and heart;

In the absence of signs of transfusion hypervolemia (CVP below 15 cm H2O.

Art.) continue infusion therapy using rheopolyglucin or dextran or 5%

glucose solution at a rate of up to 500 ml/hour, monitoring the readings every 15 minutes;

If blood pressure cannot be stabilized quickly, proceed to the next stage.

3. If in/ fluid administration is contraindicated or unsuccessful, introduce peri-

spherical vasodilators - sodium nitroprusside at a rate of 15 - 400 mcg/min or

isoket 10 mg in infusion solution intravenously.

4. Inject dopamine(dopamine) 200 mg in 400 ml of 5% glucose solution in the form of intravenous

rivinny infusion, increasing the infusion rate from 5 mcg/kg/min) until a minimum

low sufficient blood pressure;

No effect - additionally prescribe norepinephrine hydrotartrate 4 mg in 200 ml

5% glucose solution intravenously, increasing the infusion rate from 5 mcg/min to reach

reducing the minimum sufficient blood pressure

Main dangers and complications:

Inability to stabilize blood pressure;

Pulmonary edema due to increased blood pressure or intravenous administration

liquids;

Tachycardia, tachyarrhythmia, ventricular fibrillation;

Asystole;

Recurrence of anginal pain;

Acute renal failure.

List of essential medications:

1.*Morphine hydrochloride 1% 1 ml, amp

2.*Heparin 5 ml vial, with activity 5000 units in 1 ml

3.*Alteplase 50 mg powder for the preparation of infusion solution, fl

4.*Streptokinase 1,500,000 IU, powder for solution, fl

5.*Sodium chloride 0.9% 500 ml, fl

6.*Glucose 5% 500 ml, fl

7.*Reopoliglucin 400 ml, fl

8.*Dopamine 4% 5 ml, amp

List of additional medications

1.*Fentanyl 0.005% 2 ml, amp

2.*Droperidol 0.25% 10 ml, amp (fl)

3.*Diazepam 0.5% 2 ml, amp

5.*Isosorbide dinitrate (isoket) 0.1% 10 ml, amp

6.*Norepinephrine hydrotartrate 0.2% 1 ml, amp

Indicators of the effectiveness of medical care:

Relief of pain syndrome.

Relief of rhythm and conduction disturbances.

Relief of acute left ventricular failure.

Stabilization of hemodynamics.

With severe insufficiency of contractility of the left ventricle, the volume of blood ejected by the heart into the arterial network. Usually it is so small that it cannot be compensated by vascular resistance, and the blood supply to all organs is reduced to a critical minimum.

This condition is called cardiogenic shock. It is diagnosed with myocardial infarction, severe rhythm disturbance, myocarditis, as well as with acute disorder intracardiac hemodynamics with defects. Patients require urgent medical assistance in stationary conditions.

Read in this article

Causes of development of cardiogenic shock

The development of shock due to the inability of the heart to pump blood into the arteries is the leading cause of death from myocardial infarction. But similar complication It also happens with other diseases of the heart and blood vessels:

myocardiopathy,
myocardial inflammation,
heart tumor,
toxic damage to the heart muscle,
heavy,
injury,
blockage of the pulmonary artery by a thrombus or embolus.

Cardiogenic shock in 75% of cases is associated with dysfunction of the left ventricle; much less often, it is caused by a rupture of the interventricular septum or damage to the right side of the heart.

When a state of shock occurs against the background of myocardial infarction, the following risk factors have been identified:

elderly patients,
have diabetes mellitus,
extensive area of necrosis, more than 40% of the left ventricle,
(penetrates the entire wall of the heart),
the ECG shows abnormalities in leads 8 or 9,
EchoCG revealed a large zone of decreased wall motion,
repeated heart attack with arrhythmia,

Classification of pathology

Depending on the causes, cardiogenic shock can take the form of reflex, true and arrhythmic. The first and last are more related to collapse, their course is easier, and the chances of hemodynamic recovery are much higher.

Reflex

Associated with pain syndrome, irritation of receptors on back wall left ventricle. This reflexively causes a drop in blood pressure due to a sharp dilation of blood vessels. It is considered the mildest of shock conditions, since after pain relief, the patient’s condition quickly recovers, and blood pressure increases. It is dangerous only in case of untimely diagnosis and lack of treatment of a heart attack; it can turn into true shock.

True for heart attack

Occurs with extensive myocardial necrosis; if the affected area is close to 40%, then the reaction of the heart muscle to vasoconstrictor drugs is absent. This pathology is called unresponsive true cardiogenic shock; the patient has virtually no chance of cure.

Reduced blood supply to organs leads to the following consequences:

blood circulation disorders,
formation,
decreased brain function,
acute liver and kidney failure,
the formation of erosions or ulcers in the digestive tract,
decreased blood oxygen saturation,
stagnation in the pulmonary system,
a shift in the blood reaction to the acidic side.

A feature of the progression of shock is the formation of “ vicious circle": low blood pressure impairs blood flow in coronary vessels, leads to the spread of the infarction area, which causes a drop in contractile function and increases the signs of shock.

Arrhythmic

In this case, weakening of cardiac activity occurs against the background of a low or very high pulse rate. This happens when there is a complete blockade of the conduction of cardiac impulses from the atria to the ventricles or during an attack ventricular tachycardia, atrial fibrillation. If it is possible to normalize the rhythm of contractions, then the main hemodynamic parameters can be restored.

Symptoms of shock development

Patients with increasing cardiogenic shock are inhibited, but there are brief episodes motor excitement. Consciousness gradually weakens, there are complaints of dizziness, darkening of the eyes, frequent and irregular heartbeat. There is pain behind the sternum, cold sweat.

The skin turns pale and acquires a bluish-gray tint, the nails become cyanotic when pressed White spot disappears for more than 2 seconds. Wrist pulse is weak or absent, less than 90 mmHg. Art. (systolic), muffled heart sounds, arrhythmia. A characteristic feature failure of cardiac activity is a gallop rhythm.

In severe cases, signs of pulmonary edema increase:

bubbling breathing;
attacks of suffocation;
cough with pinkish sputum;
dry and fine bubbling moist rales in the lungs.

When erosions of the stomach and intestines form, palpation of the abdomen becomes painful, pain occurs in epigastric region, vomiting blood, congestion lead to liver enlargement. Typical manifestation shock is a decrease in urine output.

Watch the video about cardiogenic shock and its manifestations:

Diagnostic methods

The main signs of cardiogenic shock are:

systolic pressure is up to 90, and pulse pressure is less than 20 mm Hg. Art.,
urine output per hour does not exceed 20 ml,
disturbance of consciousness,
cyanosis of the limbs,
weak pulse
cold sweat.

ECG for diagnosing cardiogenic shock

Data additional methods research:

Blood test - increased bilirubin, urea, creatinine. Hyperglycemia ( high level glucose) as decompensation or first signs diabetes mellitus, a reaction to the release of stress hormones.
Coagulogram – increased blood clotting activity.
and – signs of extensive necrosis of the heart muscle.

Treatment Options

The goal of medical care for cardiogenic shock is to increase blood pressure to prevent the death of cells in vital organs.

Urgent Care

The administration of drugs to stabilize blood circulation begins even before transporting the patient to the inpatient department and does not stop until the effect is achieved. The main means for this can be: Dopamine and Norepinephrine. At the same time, intensive analgesic and antiarrhythmic therapy is carried out. Inhalation of oxygen and nitric oxide (pain relief) is indicated.

Drug therapy

After entering the ward intensive care or resuscitation continues vasoconstrictor drugs, which is complemented intravenous infusions plasma substitutes (Reopoliglucin, polarizing mixture), injections of Heparin, Prednisolone.

To restore rhythm, 10% is used more often at a dose of 100 - 120 mg; it also helps to increase the resistance of the myocardium to hypoxia. With the help of droppers, disturbances in blood electrolytes and acid-base balance are restored.

When blood glucose levels increase, use intramuscular injection insulin preparations short acting(Actrapid). The criterion for the effectiveness of therapy is an increase in pressure to 90 mm Hg. Art.

Surgical intervention

If carried out drug therapy turned out to be ineffective, and this occurs in approximately 80% of cases, then intra-arterial is recommended. With this method in thoracic region aorta through femoral artery a catheter is inserted, the balloon of which moves synchronously with the contractions of the heart, enhancing its pumping function.

The main tool that can significantly reduce the risk fatal outcome, is plastic surgery of the coronary arteries. If three main vessels supplying the myocardium are blocked, emergency bypass surgery is performed.

Intra-arterial balloon counterpulsation with cardiogenic shock

Observation

All therapeutic measures are carried out strictly under the control of blood pressure, pulse, and urine output. Using a catheter inserted into pulmonary artery, an indicator such as pulmonary capillary wedge pressure can be determined; it can be used to assess the preload on the heart muscle. EchoCG and angiography allow you to study the volume of cardiac output.

Forecast

A favorable prognosis may be with reflex cardiogenic shock in case of elimination of the pain syndrome, or arrhythmogenic shock after restoration of normal heart contractions. If shock occurs against the background of extensive cardiac damage, especially in the areactive form, then the mortality rate in such cases is extremely high.

Cardiogenic shock is extreme degree insufficiency of contractile function of the heart. It complicates the course of extensive pain, and may be due to pain or arrhythmia. Manifestations are associated with poor blood flow from the left ventricle into the arterial network. The main sign is systolic indicator pressure below 90 mm Hg. Art.

In true cardiogenic shock, there is usually a weak response to the administration of drugs to narrow blood vessels, so emergency surgery may be required to save the patient's life.

Prevention

To avoid cardiogenic shock, it is necessary to prevent myocardial infarction.

To get rid of factors that increase its risk:

bad habits;
excessive consumption of fatty, salty foods;
stress;
lack of sleep;
excess weight.

For diseases and pathological conditions that lead to a heart attack (for example, coronary disease heart disease, atherosclerosis, hypertension, thrombophilia), undergo appropriate preventive therapy.

Depending on the disease, it may include taking statins and polyunsaturated acids(for atherosclerosis, ischemic heart disease), ACE inhibitors or beta-blockers (for hypertension), antiplatelet agents (for atherosclerosis, thrombophilia).

For prevention acute myocarditis start treatment on time infectious diseases. Always when body temperature rises and feeling unwell consult a doctor and do not self-medicate. For systemic rheumatism during exacerbations, immediately begin the treatment prescribed by your rheumatologist.

For prevention, if you have an increased risk of its occurrence, take antiarrhythmic drugs, which were prescribed to you by a cardiologist or arrhythmologist. Or undergo installation of a pacemaker with defibrillation-cardioversion function, if indicated.

Go once every 1–2 years preventive examination see a cardiologist if you are healthy. Once every 6 months – if you suffer from cardiovascular diseases, endocrine disorders(First of all, the risk of heart attack is increased with diabetes).

If you have already experienced one myocardial infarction, take it seriously preventive measures, since with a second heart attack the risk of cardiogenic shock and death increases significantly.