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Q J Med 2001; 94: 57-67
© 2001 Association of Physicians

Review

Revascularization for cardiogenic shock

C.H. Davies

From the Department of Cardiology, Oregon Health Sciences University, Portland, Oregon, USA


   Introduction
 
Despite the availability of invasive circulatory monitoring, inotropes and thrombolysis, mortality from cardiogenic shock remains in excess of 50%, and continues to account for the deaths of between 7% and 11% of patients admitted with myocardial infarction.1–3 In the majority of these patients, the problem is one of overwhelming left ventricular damage and, intuitively, revascularization should be the primary therapeutic strategy. However, attempts to prove this have been fraught with difficulty, and the randomized trial paradigm that revolutionized our approach to acute cardiology appears to have faltered. This review examines the features of cardiogenic shock that have hindered attempts to improve its outcome, discusses whether current evidence is sufficient to support a policy of revascularization and explores the potential value of approaches aimed at minimizing reperfusion damage.


   Diagnosis and aetiology
 
The development of cardiogenic shock is rarely unexpected, most patients who develop shock do so within 48 hours of admission, with only 10% . . . [Full Text of this Article]


   Pathophysiology of shock due to overwhelming ventricular damage
 
Coronary occlusion
Microvascular damage
Myocyte necrosis and ischaemic dysfunction
Neuroendocrine responses
Reperfusion injury

   Management of shock due to overwhelming left ventricular damage
 
Inotropes and supportive therapies
Mechanical LV assist devices and transplantation
Myocardial reperfusion
Thrombolysis
Intra-aortic balloon pumping
Intra-aortic balloon-pump-assisted thrombolysis
Mechanical revascularization

   Prospects for maximizing myocardial salvage
 
Neutrophil and platelet function
Myocyte protection (Figure 3Go)

   Conclusions
 

   Trials glossary
 

   Notes
 

   References
 

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