27 Nov 2024
Cardiogenic shock, a common presentation of heart disease, is a major therapeutic challenge. This is the result of a new review - first author Dr. Dr. Lüsebrink - published in the renowned journal "The Lancet".
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Whether acute myocardial infarction or chronic heart failure, cardiac arrhythmia, valve disease or even a severe pulmonary embolism: many paths lead to cardiogenic shock. "Ultimately, it can be the common final stage of all these diseases, whereby the reduced pumping capacity of the heart leads to a circulatory disorder in all organs, which can lead to multi-organ failure," says Leonhard Binzenhöfer. Data on the overall incidence of the disease varies internationally. However, it can be said that it affects around five to 15 percent of patients with a heart attack," emphasizes Enzo Lüsebrink.
And one thing is clear: if a person is admitted to hospital with cardiogenic shock, their life is often in acute danger. "These are usually cases for the intensive care unit," Lüsebrink continues, "and the therapeutic options that have been proven to be effective are still limited."
Firstly: Medication
In addition to optimizing the body's fluid balance, the primary options for helping patients with cardiogenic shock are drugs that increase the pumping power of the heart muscle and maintain blood pressure. However, "the findings on the effectiveness of the substances in different patient groups, the procedure in the event of a lack of response to an initial therapy strategy and the complication rates are limited and were partly derived from studies that focused on other forms of shock," explains Leonhard Binzenhöfer.
Secondly: mechanical circuit support systems
"The importance of mechanical support systems," says Lüsebrink, "has increased significantly in recent years." In particular, the cardiologist talks about VA-ECMO and Impella. The latter is a minimally invasive pump inserted into the heart that can pump up to five and a half liters of blood per minute through the body. "For an adult, it means substantial, if not complete, relief and support of left ventricular function," Binzenhöfer continues. This has now been demonstrated for the first time in a randomized controlled trial for patients with cardiogenic shock following a heart attack. In other words, more patients survived with Impella than without the small pump. For VA-ECMO - a bedside heart-lung machine - there is as yet no evidence of a survival benefit from a randomized controlled trial.
Thirdly: Treatment of the underlying disease
"A very important point," says Binzenhöfer: "If a patient's infarction can be repaired quickly by reopening the affected coronary vessel, then they have a good chance of recovering or at least stabilizing any pump dysfunction that initially existed." The benefit of cardiac catheterization and stent implantation in patients in infarction-related shock has been proven by studies with the highest level of evidence. For other underlying diseases that cause cardiogenic shock, the data is unfortunately not yet sufficient, although new catheter-based procedures are constantly expanding the range of treatment options - for example, special suction catheters for pulmonary embolism.
Fourthly: the healthcare system
According to the Munich researchers, there is also a care-related question: Does it make sense for emergency physicians to take patients directly to a specialized facility such as a university hospital? Or is it more advantageous to treat these patients as quickly as possible at a smaller facility and only transfer them to a large center if, for example, a mechanical circulatory support system is required for stabilization? Leonhard Binzenhöfer: "We are seeing the first promising data on this question. It seems to be advantageous if a large center is connected to several clinics and coordinates the care of these patients via so-called shock teams consisting of specialists in intensive care medicine, cardiology and cardiac surgery. In this model, first responders or colleagues at smaller clinics would contact a central shock team, work out the best treatment strategy together and organize transport if necessary."
As Enzo Lüsebrink says, this could also help "to improve our treatment and hopefully further reduce the still high mortality rate of 40 to 50 percent among patients."
Publikation:
Cardiogenic shock
Enzo Lüsebrink, Leonhard Binzenhöfer, Prof Marianna Adamo, Prof Roberto Lorusso, Prof Alexandre Mebazaa, Prof David A Morrow, et al.
Review Volume 404, Issue 10466p2006-2020, November 16, 2024
DOI: 10.1016/S0140-6736(24)01818-X