Cardiogenic shock 2 degrees diagnosis. Extreme insufficiency of the contractile function of the heart or cardiogenic shock: are there any chances? Data from additional research methods

- this 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 centralization of blood circulation (pallor, decrease in skin temperature, the appearance of stagnant spots), impaired consciousness. The diagnosis is made on the basis of the clinical picture, ECG results, tonometry. The goal of treatment is to stabilize hemodynamics, restore heart rate. As part of emergency therapy, beta-blockers, cardiotonic drugs, narcotic analgesics, and oxygen therapy are used.

Complications

Cardiogenic shock complicated by multiple organ failure (MOF). The work of the kidneys and liver is disrupted, reactions from 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. PON symptoms - spider veins on the skin, vomiting "coffee grounds", the smell of raw meat from the mouth, 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. With tonometry, a decrease in blood pressure below 90/50 mm Hg is determined. Art., pulse rate less than 20 mm Hg. Art. At the initial stage of the disease, hypotension may be absent, due to the inclusion compensatory mechanisms. Heart tones are muffled, moist small bubbling rales are heard in the lungs.
Electrocardiography. ECG in 12 leads reveals the characteristic signs of myocardial infarction: a decrease in the amplitude of the R wave, a shift segment S-T, negative T wave. There may be signs of extrasystole, atrioventricular block.
Laboratory research. Assess the concentration of troponin, electrolytes, creatinine and urea, glucose, liver enzymes. The level of troponins I and T rises already in the first hours of AMI. sign of developing kidney failure- an increase in the concentration of sodium, urea and creatinine in plasma. The activity of liver enzymes increases with the reaction of the hepatobiliary system.

When conducting a diagnosis, cardiogenic shock should be distinguished from dissecting aortic aneurysm, vasovagal syncope. With aortic dissection, pain radiates along the spine, persists for several days, and is undulating. Missing with syncope major changes on the ECG, in the anamnesis - painful effect or psychological stress.

Treatment of cardiogenic shock

Patients with acute heart failure and signs state of shock are urgently hospitalized in a cardiological hospital. A resuscitator should be present as part of the ambulance team traveling to such calls. On prehospital stage oxygen therapy is carried out, central or peripheral venous access is provided, according to indications, thrombolysis is performed. The hospital continues the treatment started by the SMP team, which includes:

Medical correction of violations. Loop diuretics are administered to control pulmonary edema. 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 volume of infusion is considered sufficient when this figure reaches 15 units. Appointed antiarrhythmic drugs(amiodarone), cardiotonic, narcotic analgesics, steroid hormones. Severe hypotension is an indication for the use of norepinephrine through a perfusor syringe. With persistent heart rhythm disturbances, cardioversion is used, with severe respiratory failure - mechanical ventilation.
High tech help. In the treatment of patients with cardiogenic shock, such high-tech methods as intra-aortic balloon counterpulsation, artificial ventricle, 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 present.

Forecast and prevention

The prognosis is unfavorable. Mortality is over 50%. It is possible to reduce this indicator 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 is significantly higher among patients who underwent surgical intervention aimed at restoring the patency of damaged coronary vessels.

Prevention consists in preventing the development of MI, thromboembolism, severe arrhythmias, myocarditis and heart injury. To this end, it is important to take preventive courses of treatment, maintain a healthy and active image life, avoid stress, follow the principles of a healthy diet. When the first signs of a cardiac catastrophe occur, an ambulance call is required.

Cardiogenic shock is left ventricular failure acute stage. It develops in 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 is not even able to be compensated by an increase in vascular resistance. As a result, blood pressure decreases and blood circulation in vital organs is disturbed.

Features of the disease

Cardiogenic shock occurs as a result of a violation of the supply of oxygen to the organs. With a decrease in cardiac output, there is a decrease in perfusion to all organs. Shock causes microcirculation disorder, microthrombi are formed. The functioning of the brain is disrupted, acute insufficiency kidneys and liver, trophic ulcers can form in the digestive organs, due to a deterioration in blood supply to the lungs, metabolic acidosis develops.

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

The classification of cardiogenic shock is discussed below.

The following video tells about 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. Violations of the functions due to changes in the frequency of contractions of the heart. After the heart rhythm is restored, the effects of shock disappear.

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

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

Read about the criteria and causes of cardiogenic shock below.

Causes

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

Immediate causes of the disease:

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

As a result of turning off some part of the myocardium, the heart cannot fully provide blood supply to the body and the brain as well. In addition, 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 chest pain radiating to upper limbs, shoulder blades and neck;
feeling of fear;
confusion;
increased heart rate;
a fall systolic pressure up to 70 mm Hg;
earthy complexion.

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

Diagnostics

Clinical manifestations of cardiogenic shock:

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

The following additional methods of examination are carried out:

electrocardiogram for the purpose of studying focal changes in the myocardium;
echocardiogram to assess the contractile features;
anchiography to analyze the state of blood vessels.

Treatment of cardiogenic shock in myocardial infarction is discussed below.

Treatment

Cardiogenic shock is a condition in which it is necessary to cause as soon as possible ambulance. And even better - a specialized resuscitation cardiology team.

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

Urgent Care

First aid 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;
introduce thrombolytics, anticoagulants;
in the absence of heart contractions, defibrillate;
execute indirect massage hearts.

Read more about drugs for cardiogenic shock.

The following video is about the treatment of cardiogenic shock:

Medical method

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

Narcotic analgesics are used. It is necessary to start dripping a glucose solution intravenously, and to increase the pressure - dosed vasoprocessor agents (norepinephrine or dopamine), hormonal drugs.
As soon as the pressure returns to normal, the patient should be given drugs to expand the coronary vessels and improve microcirculation. This is sodium nitrosorbide or. Hydrocarbonate is also shown.
If the heart has stopped, an indirect massage is performed, mechanical ventilation, norepinephrine, lidocaine, gibrocarbonate are re-introduced. If necessary, perform defibrillation.

It is very important to try to deliver the patient to the hospital. IN modern centers apply such latest ways salvation as a counterpulsation. A catheter with a balloon at the end is inserted into the aorta. During diastole, the balloon expands, and during systole, it collapses. 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 the patency of the arteries, save the myocardium, break the vicious circle of cardiogenic shock. Such an 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;
avoidance of stress.

It is very important to take the medicines prescribed by the doctor, as well as timely stop the pain and eliminate the violation of heart contractions.

Complications in cardiogenic shock

With cardiogenic shock, there is a violation of the blood circulation of all organs of the body. Signs of hepatic and renal failure may develop, trophic ulcer digestive organs,

Reduced pulmonary blood flow, which leads to oxygen hypoxia and increased acidity of the blood.

Forecast

Mortality in cardiogenic shock is 85-90%. Only a few make it to the hospital and recover successfully.

For more useful information on cardiogenic shock, see the following video:

In severe insufficiency of the contractility of the left ventricle, the volume of blood ejected by the heart into 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 arrhythmia, myocarditis, as well as with acute disorder intracardiac hemodynamics in malformations. Patients require urgent medical assistance in stationary conditions.

Read in this article

Causes 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 a violation of the left ventricle, much less often it is caused by a 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,
extensive area of necrosis, more than 40% of the left ventricle,
(penetrates the entire wall of the heart),
there are abnormalities in the EKG in 8 or 9 leads,
echocardiography revealed a large area of decreased wall motion,
re-infarction 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 restoring hemodynamics are much higher.

Reflex

Associated with pain syndrome, irritation of receptors on back wall left ventricle. Reflexively, this causes a drop in blood pressure due to a sharp expansion of blood vessels. It is considered the easiest of the shock conditions, since after the pain is relieved, the condition of the patients is quickly restored, the blood pressure rises. It is dangerous only in case of untimely diagnosis and lack of treatment of a heart attack, it can turn into true shock.

True with a heart attack

It occurs with extensive myocardial necrosis, if the affected area is close to 40%, then there is no reaction of the heart muscle to vasoconstrictor drugs. This pathology is called areactive true cardiogenic shock, for the patient there is practically no chance of a cure.

Reduced blood supply to organs leads to the following consequences:

circulatory disorder,
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 reaction of the blood to the acid 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 infarct area, which causes a drop in contractile function and enhances the signs of shock.

arrhythmic

The weakening of cardiac activity in this case occurs against the background of a low or very high pulse rate. This happens with 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 it is possible to restore the main hemodynamic parameters.

Symptoms of shock development

Patients with an increase in cardiogenic shock are inhibited, but there are brief episodes motor excitation. Consciousness is gradually weakening, 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 becomes bluish-gray, the nails are cyanotic, when pressed, the white spot disappears for more than 2 seconds. Wrist pulse weak or absent, below 90 mm Hg. Art. (systolic), muffled heart sounds, arrhythmia. characteristic feature heart failure is the gallop rhythm.

At severe course increasing signs of pulmonary edema:

bubbling breath;
asthma attacks;
cough with pinkish sputum;
dry and small bubbling wet rales in the lungs.

With the formation of erosions of the stomach and intestines, palpation of the abdomen becomes painful, pain occurs in epigastric region, vomiting blood, congestion lead to enlargement of the liver. 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 up to 90, and pulse - less than 20 mm Hg. Art.,
urine output per hour does not exceed 20 ml,
disturbance of consciousness
extremity cyanosis,
weak pulse,
cold sweat.

ECG in the diagnosis of cardiogenic shock

Data additional methods research:

Blood test - elevated 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 introduction of drugs to stabilize blood circulation begins even before the patient is transported to the inpatient department and does not stop until the effect is obtained. The main means for this can be:, Dopamine and Norepinephrine. At the same time, intensive analgesic and antiarrhythmic therapy is carried out. Inhalations of oxygen and nitric oxide are shown (pain relief).

Drug therapy

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

To restore the 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, the violation of blood electrolytes and acid-base balance is restored.

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

Surgical intervention

If the drug therapy performed was not very effective, and this occurs in about 80% of cases, then intra-arterial therapy is recommended. With this method, in 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 fatality, is coronary artery plasty. When blockage of the three main vessels that feed the myocardium, an urgent bypass is performed.

Intra-arterial balloon counterpulsation with cardiogenic shock

Observation

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

Forecast

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

Cardiogenic shock is an extreme degree of insufficiency of the contractile function of the heart. It complicates the course of an extensive, possibly due to pain syndrome, arrhythmias. Manifestations are associated with a weak flow of blood from the left ventricle into the arterial network. The main symptom is systolic index pressure below 90 mm Hg. Art.

In true cardiogenic shock, there is usually little response to vasoconstrictor drugs, and emergency surgery may be required to save the patient's life.

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 organs of a person. Cardiogenic shock and its clinical manifestations usually develop almost immediately after myocardial infarction. What is cardiogenic shock, pathogenesis, classification, clinic and treatment will be covered further.

Severity

According to the clinic, cardiogenic shock can be divided into 3 degrees of severity:

At the first degree of severity, shock can last no more than 5 hours. Clinical manifestations are not expressed. Arterial pressure is slightly reduced, the heartbeat is slightly rapid. First-degree cardiogenic shock 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 frequent, and swelling of the lungs occurs, the left ventricle of the heart can hardly cope with its duties, that is, heart failure is observed. This degree pathology responds very slowly to therapeutic measures.
The state of shock at 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 response to resuscitation if it happens, it is short-lived.

Cardiogenic and clinic

Pathology with her clinical manifestations It 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 timely measures are not taken to eliminate the symptoms, then given form disease can progress to next stage.
True. massive heart attack myocardium, in which the tissues of the left ventricle of the heart die. When tissue necrosis exceeds 50%, then, despite all the resuscitation measures taken, the patient dies.
Areactive. The most severe form of pathology, in which there is a multifactorial pathogenesis of cardiogenic shock with its clinical manifestations. Areactive cardiogenic shock is not amenable to any therapy and always leads to the death of the patient.
Arrhythmic. Pathology is associated with a violation of the heart rhythm, that is, with an increase or slowdown in the pulse. If resuscitation of the patient is carried out in a timely manner, then the condition can be normalized.

Pathogenesis of cardiogenic shock and clinic depending on the causes

The main causes of cardiogenic shock are:

Myocardial infarction. In this state, the following clinical picture: stitching pain in the sternum, panic fear death, shortness of breath and pallor of the skin, lack of effect from taking nitroglycerin.
Violation of the heart rhythm. A person develops tachycardia, arrhythmia, or bradycardia.

How to understand that shock has come

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

In shock caused by myocardial infarction, the patient always experiences a strong pain sensation in and behind the chest. In most cases, pain is followed by a feeling of fear of death, panic begins.
If the cause of cardiogenic shock was a violation of the heart rhythm, then the patient may begin tachycardia or bradycardia immediately after the onset of chest pain.
appears severe weakness, it becomes difficult for the patient to breathe, sometimes coughing up blood may appear. The skin on the head, neck and chest of the patient becomes earthy or gray.

Signs of cardiogenic shock

Regardless of the reason, but varying degrees the following symptoms of cardiogenic shock appear, which are the result of low blood pressure: the patient begins to sweat profusely, the lips and nose take on a blue tint, the veins in the neck swell strongly, the hands and feet become cold.

If the patient at the time of cardiogenic shock is not provided with urgent medical care, then he first loses consciousness, as the cardiac and brain activity and then dies.

Diagnosis of cardiogenic shock

To diagnose cardiogenic shock, the following activities are carried out in the clinic:

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 the clinic of cardiogenic shock is to call an ambulance. And before her arrival, it is necessary to seat the patient, free the neck and chest from everything unnecessary, give him a nitroglycerin tablet under the tongue.

Upon the arrival of paramedics, the following activities are carried out:

To alleviate the patient's condition and eliminate pain, painkillers are used, which are mainly related to narcotic medicines. This is "Promedol", "Fentanyl".
To increase blood pressure, drugs such as Dopamine, Norepinephrine can be used.
The patient is being drip introduction physiological saline and glucose.
As used "Prednisolone".
"Panangin" helps to normalize the pulse.
If necessary, defibrillation or chest compressions are performed.
In order to eliminate pulmonary edema, diuretics are prescribed, in particular Furosemide.
To exclude thrombosis, the patient is injected with "Heparin".
In order to establish the work of the metabolic processes of the body, the patient is injected with a solution of sodium bicarbonate.
Oxygen inhalations are used to normalize the level of oxygen in the body.

All of the above activities are carried out in an ambulance on the way 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 on the basis of what served as the impetus for development.

Since the main cause of cardiogenic shock is myocardial infarction, the patient undergoes thrombolytic therapy to eliminate the blockage in the coronary artery. If the patient is in a coma, then he is given a tracheal intubation. This procedure helps to 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, then the doctor may decide to perform emergency surgery in order to save the patient's life.

To combat the clinical manifestations of cardiogenic shock, such methods are used surgical interventions:

Coronary artery bypass grafting. The procedure is to create an additional bloodstream, which is a bridge used before 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 timely assistance was provided for cardiogenic shock of the first degree and its clinic, and the patient was immediately taken to the hospital, then we can say that the patient will survive. In 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 he can no longer be helped, 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:

Rejection bad habits. If a person often smokes and abuses alcohol, and his diet leaves much to be desired, then sooner or later the body will begin to malfunction. As a result of poor-quality nutrition, smoking and drinking alcohol, the walls of blood vessels begin to form atherosclerotic plaques, because of which the load on the heart increases significantly and, as a result, the work of all vital organs of the body worsens.
Controlling the level of physical activity. It is important that everyone physical exercise on the body were regular and uniform. So, excessive loads can cause enormous harm to the body, while sedentary image life affects him just as detrimentally, so it is necessary to maintain a balance, that is, physical activity must be alternated with rest. If it is not possible to engage in any kind of sport, then you need to make 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 relax after labor day.
Preventive examination. People with hereditary factors or those who are prone to the development of diseases of the cardiovascular system, you need to be examined every six months by your doctor with the delivery of all necessary analyzes. This will help to detect the disease in time and prevent the development serious pathologies.
Stress and emotional tension. It is very important to remember that during stressful situations or emotional surges, the level of the adrenaline hormone increases dramatically, which adversely affects the functioning of the cardiovascular system, so it is very important to be as calm as possible with any life situation, the only way to achieve that the heart long years will work without a hitch.
healthy eating. The patient's diet should include required amount useful macro- and microelements. For this, it is important to follow a special diet.

Now the pathogenesis, clinic and treatment of cardiogenic shock have become clear. Heart disease is often fraught with a fatal outcome 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 steady drop in blood pressure. Top pressure while falling below 90 mm Hg. In most cases, this situation occurs as a complication of myocardial infarction, and you should be prepared for its occurrence in order to help the core.

The occurrence of cardiogenic shock contributes (especially in 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 fall into dangerous conditions kidneys (the skin clearly turns pale and its moisture increases), the central nervous system, pulmonary edema occurs. Prolonged persistence of the state of shock invariably leads to the death of the core.

Due to its importance, cardiogenic shock microbial 10 is separated into a separate section - R57.0.

Attention. True cardiogenic shock is the most dangerous manifestation AHF (acute heart failure) of the left ventricular type, due to severe myocardial damage. Probability lethal outcome in this state is from 90 to 95%.

Cardiogenic shock - causes

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

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

acute insufficiency 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 MI;
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:

anterior infarction,
the patient has a history of myocardial infarction,
old age of the patient,
the 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. developmental pathogenesis

For the development of true cardiogenic shock, the death of more than 40% of LV myocardial cells is necessary. At the same time, the remaining 60% should start working at a double load. The critical decrease that occurs immediately after a coronary attack systemic circulation stimulates the development of response, compensatory reactions.

Due to the activation of the sympathetic-adrenal system, as well as the action of glucocorticosteroid hormones and the renin-angiotensin-aldosterone system, the body tries to increase blood pressure. Due 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, an increase in myocardial oxygen demand, vasospasm of the microvasculature, and an increase in cardiac afterload.

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

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

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

Violation of LV relaxation in diastole contributes to rapid rise 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, there is an aggravation of the already existing ischemia and a worsening of the patient's condition.

Attention. Prolonged tissue and organ hypoxia leads to a violation 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 an intense pain syndrome. The severity of pain in this case 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 stopped by the introduction 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 shortage of circulating blood volume due to plasma leakage from the vessel into the interstitium. This complication leads to a decrease in blood flow to the heart.

Attention. Infarcts with posterior localization are characterized by bradyarrhythmia ( low frequency heart rate), which increases the severity of shock and worsens the prognosis.

How does arrhythmia shock develop?

The most common causes of this type of shock are:

paroxysmal tachyarrhythmia;
ventricular tachycardia;
atrioventricular blockade of the second or third degree;
sinoatrial blockade;
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.

At the basis of pathogenesis areactive shock there is a reduced ability of the heart muscle to contract. As a result, microcirculation, gas exchange are disturbed 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 need of the heart for oxygen;
a rapid increase in the ischemic zone in the myocardium;
the onset or worsening of symptoms pulmonary edema, in response to the introduction of vasoactive agents and an increase in blood pressure.

Cardiogenic shock - symptoms

The leading symptoms of cardiogenic shock are:

pain (high-intensity, widely radiating, burning, squeezing, pressing or "dagger character"). 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 mmHg, and mean blood pressure less than 65 and the need for vasopressor medicines in order to maintain blood pressure. Average blood pressure is calculated based on the formula = (2 diastolic blood pressure + systolic) / 3). In patients with severe arterial hypertension and original high pressure, the level of systolic blood pressure in shock can be more than 90;
severe shortness of breath;
the appearance of a thready, weak pulse, tachycardia of more than one hundred beats per minute or bradyarrhythmia of less than forty beats per minute;
microcirculation disorders and the development of symptoms of tissue and organ hypoperfusion: cold extremities, the appearance of sticky cold sweat, pallor and marbling skin, renal failure with oliguria or anuria (decrease in volume or complete absence urine), disorders acid-base balance blood and the occurrence of acidosis;
deafness of heart tones;
increasing clinical symptoms of pulmonary edema (appearance of moist rales in the lungs).

There may also be disturbances of consciousness (the appearance of psychomotor agitation, severe lethargy, stupor, loss of consciousness, coma), collapsed, unfilled peripheral veins and a positive symptom white spot(the appearance of a white, long-term non-disappearing spot on the skin back side hands or feet, after light pressure with a finger).

Diagnostics

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

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

For reference. If the data obtained are in favor of a 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 NMK (violation cerebral circulation) and long-term diabetes, cardiogenic shock may occur against the background of painless ischemia.

For fast differential diagnosis carry out:

ECG recording (against the background of clinical symptoms of shock significant changes absent); pulse oximetry (quick, non-invasive assessment of the degree of blood oxygen saturation);
monitoring of arterial pressure and pulse;
assessment of the level of plasma serum lactate (the most significant factor for the prognosis). A lactate level of more than 2 mmol/l testifies in favor of true cardiogenic shock. 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 within 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, an ambulance should be called immediately. All attempts to provide first aid on their own will only lead to a loss of time and make the patient's chances of survival zero.

Emergency care for cardiogenic shock:

Cardiogenic shock - treatment

Treatment of cardiogenic shock consists of several stages:

Holding 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;
Operational intervention.

Treatment depending on the type of shock:

Medical therapy

Ataralgesia is also shown - the introduction of NSAIDs (ketoprofen) or narcotic analgesic (fentanyl) in combination with diazepam.

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

Norepinephrine, mezaton, cordiamine, dopamine are used to normalize blood pressure. If the effect of increasing blood pressure is unstable, the introduction of hydrocortisone or prednisolone is indicated.

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

In order to normalize rheological properties blood and elimination of hypovolemia, rheopolyglucin is administered.

Also, elimination of violations of the acid-base balance of the blood, repeated anesthesia, 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. Mortality during development 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.

For pain and arrhythmogenic shock the prognosis is more favorable, as patients usually respond adequately to ongoing therapy.

For reference. There is no prevention of shock.

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

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