Cardiogenic shock 2nd degree diagnosis. Extreme degree of insufficiency of contractile function of the heart or cardiogenic shock: is there a chance? Data from additional research methods

is an extreme degree of manifestation of acute heart failure, characterized by a critical decrease in contractility myocardium and tissue perfusion. Symptoms of shock: drop in blood pressure, tachycardia, shortness of breath, signs of centralized blood circulation (pallor, decreased skin temperature, appearance of congestive spots), impaired consciousness. The diagnosis is made based on the clinical picture, ECG results, tonometry. The goal of treatment is stabilization of hemodynamics, recovery heart rate. As part of emergency treatment, beta blockers, cardiotonics, narcotic analgesics, and oxygen therapy are used.

Complications

Cardiogenic shock complicated by multiple organ failure (MOF). The functioning of the kidneys and liver is impaired, side effects are observed digestive system. Systemic organ failure is a consequence of untimely provision of medical care to the patient or a severe course of the disease, in which the rescue measures taken are ineffective. Symptoms of MODS – spider veins on the skin, vomiting “coffee grounds”, smell of raw meat from the breath, swelling of the jugular veins, anemia.

Diagnostics

Diagnosis is carried out on the basis of physical, laboratory and instrumental examination. When examining a patient, a cardiologist or resuscitator notes external signs diseases (pallor, sweating, marbling of the skin), assesses the state of consciousness. Objective diagnostic measures include:

Physical examination. Tonometry determines a decrease in blood pressure below 90/50 mmHg. Art., pulse rate less than 20 mm Hg. Art. At the initial stage of the disease, hypotension may be absent, which is due to the inclusion compensatory mechanisms. Heart sounds are muffled, moist fine rales are heard in the lungs.
Electrocardiography. A 12-lead ECG reveals characteristic signs of myocardial infarction: decreased amplitude of the R wave, displacement S-T segment, negative T wave. Signs of extrasystole and atrioventricular block may be observed.
Laboratory research. The concentration of troponin, electrolytes, creatinine and urea, glucose, and liver enzymes is assessed. The level of troponins I and T increases already in the first hours of AMI. Sign of developing renal failure- increased concentrations of sodium, urea and creatinine in plasma. The activity of liver enzymes increases with the reaction of the hepatobiliary system.

When carrying out diagnostics, it is necessary to distinguish cardiogenic shock from dissecting aortic aneurysm and vasovagal syncope. With aortic dissection, the pain radiates along the spine, persists for several days, and is wave-like. Absent during syncope major changes on ECG, in medical history - painful effect or psychological stress.

Treatment of cardiogenic shock

Patients with acute heart failure and symptoms state of shock are urgently hospitalized in a cardiology hospital. The ambulance team responding to such calls must include a resuscitator. On prehospital stage Oxygen therapy is carried out, central or peripheral venous access is provided, and thrombolysis is performed according to indications. In the hospital, treatment started by the emergency medical team continues, which includes:

Drug correction of disorders. To relieve pulmonary edema, loop diuretics are administered. Nitroglycerin is used to reduce cardiac preload. Infusion therapy is carried out in the absence of pulmonary edema and CVP below 5 mm Hg. Art. The infusion volume is considered sufficient when this figure reaches 15 units. Appointed antiarrhythmic drugs(amiodarone), cardiotonics, narcotic analgesics, steroid hormones. Severe hypotension is an indication for the use of norepinephrine through a perfusion syringe. For persistent cardiac arrhythmias, cardioversion is used, and for severe respiratory failure, mechanical ventilation is used.
High-tech assistance. When treating patients with cardiogenic shock, high-tech methods such as intra-aortic balloon counterpulsation, artificial ventricle, and balloon angioplasty are used. The patient receives an acceptable chance of survival with timely hospitalization in a specialized cardiology department, where the equipment necessary for high-tech treatment is available.

Prognosis and prevention

The prognosis is unfavorable. The mortality rate is more than 50%. This indicator can be reduced in cases where first aid was provided to the patient within half an hour from the onset of the disease. The mortality rate in this case does not exceed 30-40%. Survival rate is significantly higher among patients who underwent surgical intervention, aimed at restoring the patency of damaged coronary vessels.

Prevention consists of preventing the development of MI, thromboembolism, severe arrhythmias, myocarditis and heart injuries. For this purpose, it is important to undergo preventive courses of treatment, maintain a healthy and active image life, avoid stress, follow the principles of healthy eating. When the first signs of a cardiac catastrophe occur, an ambulance must be called.

Cardiogenic shock - left ventricular heart failure in acute stage. Develops within a few hours when the first signs appear, less often - in more late period. A decrease in the level of minute and stroke volume of blood cannot even be compensated by an increase in vascular resistance. As a result, blood pressure decreases and blood circulation in vital organs is disrupted.

Features of the disease

Cardiogenic shock occurs as a result of a disruption in the supply of oxygen to organs. As cardiac output decreases, perfusion to all organs decreases. Shock causes microcirculation disorders and microthrombi form. The functioning of the brain is disrupted, it develops acute failure kidneys and liver, trophic ulcers can form in the digestive organs, due to deterioration of blood supply in the lungs, metabolic acidosis develops.

In adults, the body compensates for this condition by reducing systemic vascular resistance and increasing the heart rate.
In children, this condition is compensated by an increase in heart rate and compression blood vessels(vasoconstriction). The latter is due to the fact that - late sign shock.

The classification of cardiogenic shock is discussed below.

The following video describes the pathogenesis and features of cardiogenic shock:

Forms

There are 3 types (forms) of cardiogenic shock:

arrhythmic;
reflex;
true.

Arrhythmic shock occurs due to or acute bradyarrhythmia as a result of complete atrioventricular block. Functional disorders are caused by changes in heart rate. After the heart rhythm is restored, the symptoms of shock disappear.

Reflex shock is the most light form and it is not caused by damage to the heart muscle, but by a decrease in blood pressure as a result pain syndrome after a heart attack. At timely treatment, the pressure returns to normal. Otherwise, a transition to true cardiogenic is possible.

True cardiogenic develops when as a result of a sharp decrease in functions left ventricle. With necrosis of 40% or more, ariative cardiogenic shock develops. Sympathomimetic amines do not help. Mortality rate is 100%.

Read below about the criteria and causes of cardiogenic shock.

Causes

Cardiogenic shock develops due to myocardial infarction, like it. Less commonly, it can occur as a complication after poisoning with cardiotoxic substances.

Immediate causes of the disease:

heavy;
disruption of the pumping function of the heart;
pulmonary artery.

As a result of the shutdown of some part of the myocardium, the heart cannot fully provide blood supply to the body and the brain as well. Plus, the affected area of the heart with coronary artery increases due to reflex spasms of nearby arterial vessels.

As a result, ischemia and acidosis develop, which leads to more severe processes in the myocardium. Often the process is aggravated by asystole, respiratory arrest and death of the patient.

Symptoms

Cardiogenic shock is characterized by:

sharp pain in the chest, radiating to upper limbs, shoulder blades and neck;
feeling of fear;
confusion;
increased heart rate;
a fall systolic pressure up to 70 mmHg;
sallow complexion.

If timely assistance is not provided, the patient may die.

Diagnostics

Clinical manifestations of cardiogenic shock:

pale skin, cyanosis;
low body temperature;
sticky sweat;
shallow breathing with difficulty;
rapid pulse;
muffled heart sounds;
decreased diuresis or anuria;
heartache.

The following additional examination methods are carried out:

electrocardiogram for the purpose of studying focal changes in the myocardium;
echocardiogram to assess contractility;
anchiography to analyze the condition of blood vessels.

Treatment of cardiogenic shock during myocardial infarction is discussed below.

Treatment

Cardiogenic shock is a condition that should be treated as soon as possible. ambulance. And even better - a specialized intensive care cardiac team.

Read below about the algorithm of actions for emergency care for cardiogenic shock.

Urgent Care

First emergency care for cardiogenic shock should be carried out immediately in the following sequence:

put the patient down and raise his legs;
provide air access;
do artificial respiration, if there is none;
administer thrombolytics, anticoagulants;
in the absence of heart contractions, perform defibrillation;
execute indirect massage hearts.

Read more about medications for cardiogenic shock.

The following video is devoted to the topic of treatment of cardiogenic shock:

Medication method

Goal of treatment: eliminate pain, increase blood pressure, normalize heart rate, prevent dilatation ischemic lesion heart muscle.

Narcotic analgesics are used. It is necessary to start drips of glucose solution intravenously, and to increase blood pressure - dosed vasoprocessor drugs (norepinephrine or dopamine), hormonal drugs.
As soon as the pressure returns to normal, the patient should be given drugs to dilate the coronary vessels and improve microcirculation. This is sodium nitrosorbide or. Hydrocarbonate is also shown.
If the heart has stopped, perform indirect massage, mechanical ventilation, and reintroduce norepinephrine, lidocaine, and bicarbonate. Defibrillation is performed if necessary.

It is very important to try to transport the patient to the hospital. IN modern centers use such newest ways salvation, like counterpulsation. A catheter with a balloon at the end is inserted into the aorta. During diastole, the balloon straightens; during systole, it falls. This ensures the filling of blood vessels.

Operation

Surgery is a last resort. This is percutaneous transluminal coronary angioplasty.

The procedure allows you to restore arterial patency, preserve the myocardium, and interrupt the vicious circle of cardiogenic shock. This operation should be carried out no later than 6-8 hours after the onset of a heart attack.

Prevention

TO preventive measures to avoid the development of cardiogenic shock include:

sport in moderation;
complete and proper nutrition;
healthy lifestyle;
avoiding stress.

It is very important to take medications prescribed by your doctor, as well as promptly relieve pain and eliminate heart contraction disorders.

Complications of cardiogenic shock

With cardiogenic shock, the blood circulation of all organs of the body is disrupted. Signs of liver and kidney failure may develop, trophic ulcer digestive organs.

Pulmonary blood flow decreases, which leads to oxygen hypoxia and increased blood acidity.

Forecast

The mortality rate for cardiogenic shock is 85-90%. Only a few make it to the hospital and recover successfully.

Even more useful information on cardiogenic shock is contained in the following video:

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 rupture 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 are cyanotic, and when pressed, the 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.

At severe course 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 the first signs of 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 in order to prevent the death of vital cells. important 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 the drug therapy was ineffective, and this occurs in approximately 80% of cases, then intra-arterial therapy is recommended. With this method, into the thoracic 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 an extreme degree of failure of the 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.

The essence of pathology

Cardiogenic shock is a consequence of acute heart failure, which occurs if the heart ceases to perform its main function, that is, to supply blood to all vital human organs. Cardiogenic shock and its clinical manifestations usually develop almost immediately after myocardial infarction. What cardiogenic shock is, pathogenesis, classification, clinical picture and treatment will be discussed further.

Severity

Cardiogenic shock can be clinically divided into 3 degrees of severity:

In the first degree of severity, shock can last no more than 5 hours. Clinical manifestations are not pronounced. Blood pressure is slightly reduced, heart rate is slightly increased. Cardiogenic shock of the first degree is easily treatable.
An attack in the second degree can last from 5 to 10 hours, but no more. Blood pressure is greatly reduced, the pulse is rapid, and swelling of the lungs occurs; the left ventricle of the heart has difficulty coping with its duties, that is, heart failure is observed. This degree pathology responds very slowly to therapeutic measures.
The state of shock in the third degree of severity lasts more than 10 hours. The pressure is very low, the lungs are very swollen, the pulse is more than 120 beats per minute. Positive reaction to resuscitation measures if it happens, it is short-term.

Cardiogenic and clinic

Pathology with her clinical manifestations is divided into 4 main forms, depending on the severity of the pathological process:

Reflex. The mildest form of pathology, which is characterized by a drop in blood pressure. If measures to eliminate symptoms are not taken in time, then this form the disease can develop into next stage.
True. Extensive heart attack myocardium, in which the tissue of the left ventricle of the heart dies. When tissue necrosis exceeds 50%, then, despite all resuscitation measures taken, the patient dies.
Areactive. The most severe form of pathology, in which a multifactorial pathogenesis of cardiogenic shock with its clinical manifestations is observed. Areactive cardiogenic shock does not respond to any therapy and always leads to the death of the patient.
Arrhythmic. The pathology is associated with heart rhythm disturbances, that is, with increased or slowed pulse. If the patient is resuscitated in a timely manner, the condition can be normalized.

Pathogenesis of cardiogenic shock and clinical picture depending on the causes

The main reasons for the development of cardiogenic shock are:

Myocardial infarction. In this condition, the following is observed: clinical picture: stabbing pain in the sternum, panic fear death, shortness of breath and pale skin, lack of results from taking nitroglycerin.
Heart rhythm disturbances. A person develops tachycardia, arrhythmia, or bradycardia.

How to understand that shock has occurred

The sooner emergency care is provided in the clinic for cardiogenic shock, the greater the chance that the patient will survive. The clinical manifestation of cardiogenic shock always depends on what particular pathology caused its development:

In shock caused by myocardial infarction, the patient always experiences severe pain in the chest area and behind it. In most cases, after the pain, a feeling of fear of death appears, and panic begins.
If the cause of cardiogenic shock is a cardiac arrhythmia, the patient may experience tachycardia or bradycardia immediately after the onset of chest pain.
appears severe weakness, it becomes difficult for the patient to breathe, and sometimes coughing up blood may appear. The skin on the patient's head, neck and chest becomes sallow or gray in color.

Signs of cardiogenic shock

Regardless of the reasons, but varying degrees the following symptoms of cardiogenic shock appear, which are the result of low blood pressure: the patient begins to sweat heavily, the lips and nose take on a blue tint, the veins in the neck swell greatly, the arms and legs become cold.

If the patient does not receive urgent medical care at the time of cardiogenic shock, he will first lose consciousness as the cardiac and brain activity and then dies.

Diagnosis of cardiogenic shock

To diagnose cardiogenic shock, the clinic carries out the following activities:

Electrocardiogram.
Ultrasonography hearts.
X-ray of the chest organs.
Biochemical analysis blood and urine, which is carried out throughout the course of treatment.

First aid for cardiogenic shock

The first thing to do in a cardiogenic shock clinic is to call an ambulance. And before her arrival, it is necessary to sit the patient down, free the neck and chest of everything unnecessary, and give him a nitroglycerin tablet under the tongue.

Upon arrival of emergency doctors, the following activities are carried out:

To alleviate the patient's condition and eliminate pain, painkillers are used, which are mainly classified as narcotic medications. This is "Promedol", "Fentanyl".
To increase blood pressure, drugs such as Dopamine and Norepinephrine can be used.
The patient undergoes drip administration saline solution and glucose.
Prednisolone is used.
Panangin helps normalize the pulse.
If necessary, defibrillation or chest compressions are performed.
In order to eliminate pulmonary edema, diuretics are prescribed, in particular Furosemide.
To prevent thrombosis, the patient is given Heparin.
In order to improve the functioning of the body's metabolic processes, the patient is injected with a solution of sodium bicarbonate.
Oxygen inhalations are used to normalize oxygen levels in the body.

All of the above activities are carried out in an ambulance on the way of the patient to the hospital.

Therapeutic measures

Upon admission of the patient to the hospital, full examination in order to determine the clinic of cardiogenic shock and treatment. Further therapy is carried out based on what served as the impetus for development.

Since the main cause of cardiogenic shock is myocardial infarction, the patient is given thrombolytic therapy to remove the “blockage” in the coronary artery. If the patient is in a coma, then tracheal intubation is performed. This procedure helps maintain the patient's breathing even in an unconscious state.

If the condition of a patient with cardiogenic shock and its clinical manifestations does not improve after drug therapy, the doctor may decide to perform emergency surgery to save the patient's life.

The following methods are used to combat the clinical manifestations of cardiogenic shock: surgical interventions:

Coronary artery bypass grafting. The procedure consists of creating an additional bloodstream, which is a bridge, used before the myocardial transplantation is performed.
Percutaneous transluminal coronary angioplasty. This operation implies full recovery the integrity of blood vessels, ensuring the normalization of the contractile function of the heart muscle.

Survival prognosis

If in case of cardiogenic shock of the first degree and its clinic, timely assistance was provided, and the patient was immediately taken to the hospital, then we can say that the patient will survive. With the second and third degrees of cardiogenic shock, mortality occurs in 70-80% of cases.

Preventive measures

If the patient is diagnosed with cardiogenic shock, then no preventive measures there is no way to help him, so it is important to take care of his health and prevent the development of any pathological processes. Disease Prevention of cardio-vascular system- This:

Refusal bad habits. If a person often smokes and abuses alcohol, and his nutrition leaves much to be desired, then sooner or later the body will begin to malfunction. As a result of poor-quality nutrition, smoking and alcohol consumption, blood vessels begin to form on the walls of blood vessels. atherosclerotic plaques, due to which the load on the heart increases significantly and, as a result, the functioning of all vital organs of the body deteriorates.
Monitoring the level of physical activity. It is important that everything physical exercise on the body were regular and uniform. So, excessive loads can cause enormous harm to the body, while sedentary lifestyle life affects him just as detrimentally, so it is necessary to maintain a balance, that is physical activity need to alternate with rest. If it is not possible to engage in any kind of sport, then you need to do daily hiking on fresh air, swim, ride a bike. You need to sleep at least eight hours a day, this time is enough to effectively rest after working day.
Preventive examination. People with hereditary factors or those who are susceptible to the development of diseases of the cardiovascular system, need to be examined every six months by the attending physician with all tests necessary tests. This will help to detect the disease in time and prevent its development. serious pathologies.
Stress and emotional tension. It is very important to remember that during stressful situations or emotional overstrain, the level of the hormone adrenaline increases sharply, which adversely affects the functioning of the cardiovascular system, so it is very important to treat any life situation, this is the only way to achieve what the heart long years will work without deviations.
Healthy eating. The patient's diet should contain required amount useful macro- and microelements. For this it is important to adhere to a special diet.

The pathogenesis, clinical picture and treatment of cardiogenic shock have now become clear. Heart disease is often fraught with death for the patient, so it is very important to follow all of the above recommendations and, at the slightest suspicion of any pathology, immediately seek the help of specialists.

Cardiogenic shock is characterized by a sustained drop in blood pressure. Upper pressure at the same time it falls below 90 mmHg. In most cases, this situation occurs as a complication of myocardial infarction and one should be prepared for its occurrence in order to help the core.

The occurrence of cardiogenic shock is facilitated (especially of the left ventricular type), in which many myocardial cells suffer. The pumping function of the heart muscle (especially the left ventricle) is impaired. As a result, problems begin in target organs.

First of all they get into hazardous conditions kidneys (the skin clearly turns pale and its humidity increases), central nervous system, pulmonary edema occurs. Prolonged persistence of a state of shock invariably leads to the death of the core.

Due to its importance, cardiogenic shock ICD 10 is allocated to a separate section - R57.0.

Attention. True cardiogenic shock is the most dangerous manifestation AHF (acute heart failure) of the left ventricular type, caused by severe myocardial damage. Probability fatal outcome in this condition it ranges from 90 to 95%.

Cardiogenic shock - causes

More than eighty percent of all cases of cardiogenic shock are a significant decrease in blood pressure during myocardial infarction (MI) with severe damage to the left ventricle (LV). To confirm the occurrence of cardiogenic shock, more than forty percent of the LV myocardial volume must be damaged.

Much less frequently (about 20%), cardiogenic shock develops due to acute mechanical complications of MI:

acute failure mitral valve due to rupture of the papillary muscles;
complete separation of the papillary muscles;
myocardial ruptures with the formation of an IVS defect (interventricular septum);
complete rupture of the IVS;
cardiac tamponade;
isolated right ventricular myocardial infarction;
acute cardiac aneurysm or pseudoaneurysm;
hypovolemia and a sharp decrease in cardiac preload.

The incidence of cardiogenic shock in patients with acute MI ranges from 5 to 8%.

Risk factors for the development of this complication are considered:

anterior localization of the infarction,
the patient has a history of heart attacks,
old age of the patient,
presence of underlying diseases:
- diabetes,
- chronic renal failure,
- severe arrhythmias,
- chronic heart failure,
- LV systolic dysfunction (left ventricle),
- cardiomyopathy, etc.

Types of cardiogenic shock

true;
reflex (development of pain collapse);
arrhythmogenic;
Areactive.

True cardiogenic shock. Pathogenesis of development

For the development of true cardiogenic shock, the death of more than 40% of the LV myocardial cells is necessary. In this case, the remaining 60% should start working at double load. A critical decrease occurring immediately after a coronary attack systemic blood flow stimulates the development of response, compensatory reactions.

Due to the activation of the sympathoadrenal system, as well as the action of glucocorticosteroid hormones and the renin-angiotensin-aldosterone system, the body tries to increase blood pressure. Thanks to this, in the first stages of cardiogenic shock, blood supply to the coronary system is maintained.

However, activation of the sympathetic-adrenal system leads to the appearance of tachycardia, increased contractile activity cardiac muscle, increased oxygen demand of the myocardium, spasm of microcirculatory vessels and increased cardiac afterload.

The occurrence of generalized microvascular spasm enhances blood clotting and creates a favorable background for the occurrence of DIC syndrome.

Important. Severe pain associated with severe damage to the heart muscle also aggravates existing hemodynamic disorders.

As a result of impaired blood supply, renal blood flow decreases and renal failure develops. Fluid retention by the body leads to an increase in circulating blood volume and an increase in cardiac preload.

Impaired LV relaxation in diastole contributes to rapid increase pressure inside the left atrium, venous congestion of the lungs and their edema.

A “vicious circle” of cardiogenic shock is formed. That is, in addition to compensatory maintenance coronary blood flow, the existing ischemia worsens and the patient’s condition worsens.

Attention. Prolonged tissue and organ hypoxia lead to disruption of the acid-base balance of the blood and the development of metabolic acidosis.

Pathogenesis of the development of reflex cardiogenic shocks

The basis for the development of this type of shock is intense pain. The severity of pain may not correspond to the true severity of damage to the heart muscle.

Unlike true cardiogenic shock, with timely medical care, the pain syndrome is quite easily relieved by the administration of analgesic and vascular drugs, as well as infusion therapy.

A complication of reflex cardiogenic shocks is a violation of vascular tone, an increase in capillary permeability and the appearance of a deficit in circulating blood volume due to the leakage of plasma from the vessel into the interstitium. This complication leads to decreased blood flow to the heart.

Attention. In heart attacks with posterior localization, bradyarrhythmia is characteristic ( low frequency heart rate), which increases the severity of shock and worsens the prognosis.

How does arrhythmogenic shock develop?

The most common causes of this type of shock are:

paroxysmal tachyarrhythmia;
ventricular tachycardia;
atrioventricular block of the second or third degree;
sinoatrial block;
sick sinus syndrome.

Development of areactive cardiogenic shock

Important. Unlike true cardiogenic shock, this condition can occur even with a small area of damaged LV myocardium.

The basis of pathogenesis areactive shock there is a reduced ability of the heart muscle to contract. As a result, microcirculation and gas exchange are disrupted and disseminated intravascular coagulation develops.

Areactive shock is characterized by:

high risk of death;
complete lack of response to the introduction of pressor amines to the patient;
the presence of paradoxical pulsation of the heart muscle (bulging, rather than contraction, of the damaged part of the myocardium during systole);
a significant increase in the heart's need for oxygen;
rapid increase in the ischemic zone in the myocardium;
emergence or worsening of symptoms pulmonary edema, in response to the administration of vasoactive agents and increased blood pressure.

Cardiogenic shock - symptoms

The leading symptoms of cardiogenic shock are:

pain (highly intense, widely radiating, burning, squeezing, pressing or “dagger-like” in nature). Dagger pain is most specific for slow ruptures of the heart muscle);
decrease in blood pressure (indicative of a sharp decrease of less than 90 mm Hg, and average blood pressure less than 65 and the need to use vasopressors medicines, in order to maintain blood pressure. Average blood pressure is calculated based on the formula = (2 diastolic blood pressure + systolic blood pressure)/3). In patients with severe arterial hypertension and original high pressure, the level of systolic blood pressure during shock can be more than 90;
severe shortness of breath;
the appearance of a thread-like, weak pulse, tachycardia of more than one hundred beats per minute or bradyarrhythmia of less than forty beats per minute;
disturbances of microcirculation and the development of symptoms of tissue and organ hypoperfusion: coldness of the extremities, the appearance of sticky cold sweat, pallor and marbling skin, renal failure with oliguria or anuria (decreased volume or complete absence urine), disorders acid-base balance blood and the occurrence of acidosis;
dullness of heart sounds;
increasing clinical symptoms of pulmonary edema (the appearance of moist rales in the lungs).

Impaired consciousness may also be observed (the appearance of psychomotor agitation, severe retardation, stupor, loss of consciousness, coma), collapsed, unfilled peripheral veins and a positive symptom white spot(appearance of a white, long-lasting spot on the skin back side hand or foot, after light pressure with a finger).

Diagnostics

In the vast majority of cases, cardiogenic shock develops after acute MI. If a specific problem occurs clinical symptoms cardiogenic shock must be additional research in order to differentiate shock from:

hypovolemia;
cardiac tamponade;
tension pneumothorax;
pulmonary embolism;
internal bleeding from ulcers and erosions of the esophagus, stomach or intestines.

For reference. If the data obtained indicate shock, it is necessary to determine its type (the further algorithm of actions depends on this).

It should be remembered that patients old age with NMC (violation cerebral circulation) and long-term current diabetes mellitus, cardiogenic shock may occur against the background of silent ischemia.

For quick differential diagnosis carry out:

ECG recording (against the background of clinical symptoms of shock significant changes absent); pulse oximetry (quick, non-invasive assessment of blood oxygen saturation);
blood pressure and pulse monitoring;
assessment of the level of plasma serum lactate (the most significant factor for prognosis). True cardiogenic shock is indicated by a lactate level of more than 2 mmol/l. The higher the lactate level, the higher the risk of death).

Extremely important! Remember the half-hour rule. The patient's chances of survival increase if assistance is provided in the first half hour after the onset of shock. In this regard, all diagnostic measures should be carried out as quickly as possible.

Cardiogenic shock, emergency care. Algorithm

Attention! If cardiogenic shock does not develop in a hospital, you should immediately call an ambulance. All attempts to provide first aid on your own will only lead to loss of time and will make the patient’s chances of survival zero.

Emergency care for cardiogenic shock:

Cardiogenic shock - treatment

Treatment of cardiogenic shock consists of several stages:

Carrying out general events with adequate pain relief, oxygen therapy, thrombolysis, stabilization of hemodynamic parameters;
Infusion therapy (according to indications);
Normalization of microcirculation and reduction of peripheral vascular resistance;
Increased contractility of the heart muscle;
Intra-aortic balloon counterpulsation;
Surgical intervention.

Treatment depending on the type of shock:

Drug therapy

Ataralgesia is also indicated - administration of an NSAID (ketoprofen) or a narcotic analgesic (fentanyl) in combination with diazepam.

In order to increase the contractile activity of the heart muscle, strophanthin, corglycone and glucagon are used.

To normalize blood pressure, norepinephrine, mesaton, cordiamine, and dopamine are used. If the effect of increasing blood pressure is unstable, administration of hydrocortisone or prednisolone is indicated.

When carrying out thrombolytic therapy, a combination of thrombolytics with low molecular weight heparins is administered.

For the purpose of normalization rheological properties blood and elimination of hypovolemia, rheopolyglucin is administered.

Also, elimination of disturbances in the acid-base balance of the blood, repeated pain relief, correction of arrhythmia and cardiac conduction disorders are performed.

According to indications, balloon angioplasty and coronary artery bypass grafting are performed.

Prevention, complications and prognosis

Cardiogenic shock is the most severe complication of MI. Developmental lethality true shock reaches 95%. The severity of the patient’s condition is determined by severe damage to the heart muscle, tissue and organ hypoxia, the development of multiple organ failure, metabolic disorders and DIC syndrome.

For pain and arrhythmogenic shock the prognosis is more favorable, since patients, as a rule, respond adequately to the therapy.

For reference. There is no way to prevent shock.

After eliminating shock, the patient’s treatment corresponds to therapy for CHF (chronic heart failure). There are also specific rehabilitation measures, which depend on the cause of shock.

According to indications, extracorporeal membrane oxygenation (invasive blood saturation with O2) is performed and the patient is transferred to an expert center to decide on the need for a heart transplant.