Infarction-Related Cardiogenic Shock- Diagnosis, Monitoring and Therapy–A German-Austrian S3 Guideline.
Journal
Deutsches Arzteblatt international
ISSN: 1866-0452
Titre abrégé: Dtsch Arztebl Int
Pays: Germany
ID NLM: 101475967
Informations de publication
Date de publication:
12 02 2021
12 02 2021
Historique:
received:
26
08
2020
revised:
26
08
2020
accepted:
27
10
2020
entrez:
8
4
2021
pubmed:
9
4
2021
medline:
4
5
2021
Statut:
ppublish
Résumé
The second edition of the German-Austrian S3 guideline contains updated evidence-based recommendations for the treatment of patients with infarction-related cardiogenic shock (ICS), whose mortality is several times higher than that of patients with a hemodynamically stable myocardial infarction (1). In five consensus conferences, the experts developed 95 recommendations-including two statements-and seven algorithms with concrete instructions. Recanalization of the coronary vessel whose occlusion led to the infarction is crucial for the survival of patients with ICS. The recommended method of choice is primary percutaneous coronary intervention (pPCI) with the implantation of a drug-eluting stent (DES). If multiple coronary vessels are diseased, only the infarct artery (the "culprit lesion") should be stented at first. For cardiovascular pharmacotherapy-primarily with dobutamine and norepinephrine-the recommended hemodynamic target range for mean arterial blood pressure is 65-75 mmHg, with a cardiac index (CI) above 2.2 L/min/m2. For optimal treatment in intensive care, recommendations are given regarding the type of ventilation (invasive rather than non-invasive, lungprotective), nutrition (no nutritional intake in uncontrolled shock, no glutamine supplementation), thromboembolism prophylaxis (intravenous heparin rather than subcutaneous prophylaxis), und further topics. In case of pump failure, an intra-aortic balloon pump is not recommended; temporary mechanical support systems (Impella pumps, veno-arterial extracorporeal membrane oxygenation [VA-ECMO], and others) are hemodynamically more effective, but have not yet been convincingly shown to improve survival. Combined cardiological and intensive-care treatment is crucial for the survival of patients with ICS. Coronary treatment for ICS seems to have little potential for further improvement, while intensive-care methods can still be optimized.
Sections du résumé
BACKGROUND
The second edition of the German-Austrian S3 guideline contains updated evidence-based recommendations for the treatment of patients with infarction-related cardiogenic shock (ICS), whose mortality is several times higher than that of patients with a hemodynamically stable myocardial infarction (1).
METHODS
In five consensus conferences, the experts developed 95 recommendations-including two statements-and seven algorithms with concrete instructions.
RESULTS
Recanalization of the coronary vessel whose occlusion led to the infarction is crucial for the survival of patients with ICS. The recommended method of choice is primary percutaneous coronary intervention (pPCI) with the implantation of a drug-eluting stent (DES). If multiple coronary vessels are diseased, only the infarct artery (the "culprit lesion") should be stented at first. For cardiovascular pharmacotherapy-primarily with dobutamine and norepinephrine-the recommended hemodynamic target range for mean arterial blood pressure is 65-75 mmHg, with a cardiac index (CI) above 2.2 L/min/m2. For optimal treatment in intensive care, recommendations are given regarding the type of ventilation (invasive rather than non-invasive, lungprotective), nutrition (no nutritional intake in uncontrolled shock, no glutamine supplementation), thromboembolism prophylaxis (intravenous heparin rather than subcutaneous prophylaxis), und further topics. In case of pump failure, an intra-aortic balloon pump is not recommended; temporary mechanical support systems (Impella pumps, veno-arterial extracorporeal membrane oxygenation [VA-ECMO], and others) are hemodynamically more effective, but have not yet been convincingly shown to improve survival.
CONCLUSION
Combined cardiological and intensive-care treatment is crucial for the survival of patients with ICS. Coronary treatment for ICS seems to have little potential for further improvement, while intensive-care methods can still be optimized.
Identifiants
pubmed: 33827749
pii: arztebl.m2021.0012
doi: 10.3238/arztebl.m2021.0012
pmc: PMC8192735
doi:
pii:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
88-95Investigateurs
J Bauersachs
(J)
U Boeken
(U)
J Briegel
(J)
G Delle-Karth
(G)
M Ferrari
(M)
H Figulla
(H)
A R Heller
(AR)
G Hindricks
(G)
U Janssens
(U)
M Kelm
(M)
G Michels
(G)
E Pichler-Cetin
(E)
B M Pieske
(BM)
K Pilarczyk
(K)
R Prondzinsky
(R)
A Schlitt
(A)
H Thielmann
(H)
S Willems
(S)
U Zeymer
(U)
Références
J Am Coll Cardiol. 2018 Jul 10;72(2):173-182
pubmed: 29976291
Cochrane Database Syst Rev. 2015 Mar 27;(3):CD007398
pubmed: 25812932
Crit Care Med. 2010 Jan;38(1):152-60
pubmed: 19770739
Am J Med. 2015 Jun;128(6):601-8
pubmed: 25554376
Med Klin Intensivmed Notfmed. 2016 Sep;111(6):556-9
pubmed: 27506775
Crit Care. 2016 Jul 22;20(1):226
pubmed: 27448995
Intensive Care Med. 2012 Mar;38(3):384-94
pubmed: 22310869
EuroIntervention. 2016 May 17;12(1):94-102
pubmed: 27173869
Circulation. 2005 Sep 27;112(13):1992-2001
pubmed: 16186436
JAMA Cardiol. 2020 Aug 1;5(8):965-967
pubmed: 32432650
Eur Heart J. 2017 Dec 14;38(47):3523-3531
pubmed: 29020341
Wien Klin Wochenschr. 2015 Mar;127(5-6):169-84
pubmed: 25821055
Eur Heart J. 2018 Apr 1;39(13):1065-1074
pubmed: 29452351
N Engl J Med. 2017 Dec 21;377(25):2419-2432
pubmed: 29083953
Crit Care. 2015 Dec 30;19:452
pubmed: 26715162
Cochrane Database Syst Rev. 2015 Jan 22;1:CD010381
pubmed: 25608845
JACC Cardiovasc Interv. 2019 Sep 23;12(18):1853-1859
pubmed: 31537286
Curr Opin Crit Care. 2014 Oct;20(5):493-8
pubmed: 25159477
Med Klin Intensivmed Notfmed. 2016 Sep;111(6):508-13
pubmed: 26507497
Dtsch Arztebl Int. 2012 May;109(19):343-51
pubmed: 22675405
N Engl J Med. 2013 Apr 18;368(16):1489-97
pubmed: 23594003
Shock. 2012 Apr;37(4):378-84
pubmed: 22266974
N Engl J Med. 2012 Oct 4;367(14):1287-96
pubmed: 22920912
Med Klin Intensivmed Notfmed. 2018 Sep;113(6):478-486
pubmed: 29967938
Eur Heart J. 2019 Aug 21;40(32):2671-2683
pubmed: 31274157
Eur Heart J Acute Cardiovasc Care. 2020 Mar;9(2):183-197
pubmed: 32114774
Circulation. 2019 Mar 5;139(10):1249-1258
pubmed: 30586755
Intensive Care Med. 2016 Dec;42(12):1922-1934
pubmed: 27647331
Lancet. 2018 Jan 13;391(10116):133-143
pubmed: 29128300
Clin Res Cardiol. 2012 Dec;101(12):955-62
pubmed: 22729756
Clin Drug Investig. 2016 Oct;36(10):849-56
pubmed: 27312076
Circulation. 2018 Nov 11;:
pubmed: 30586721
JAMA. 2020 Feb 18;323(7):616-626
pubmed: 31950977