Pathophysiology and management of cardiogenic shock

Early Albumin Administration in Veno-Arterial Extracorporeal Membrane Oxygenation

BACKGROUND

The clinical outcome and fluid balance of patients with veno-arterial extracorporeal membrane oxygenation (VA ECMO) or after extracorporeal cardiopulmonary resuscitation (eCPR) may be improved by addressing the high fluid demand with an early albumin administration.

METHODS

In this prospective observational study, patients supported with VA ECMO or eCPR received early albumin administration (25 g/L) to prime the VA ECMO system. These patients were compared to patients who received a regimen based solely on balanced crystalloids (crystalloid group) or a regimen based on a 1:4 volume mixture of albumin (10 g/L) and balanced crystalloids (albumin group).

RESULTS

660 VA ECMO patients (66.4% eCPR) treated between January 2017 and June 2021 were analyzed, whereby 265 patients received crystalloid fluid therapy, 269 patients received albumin therapy, and 126 patients received early albumin therapy. When compared to the albumin and crystalloid groups, patients in the early albumin treatment group had significantly lower cumulative fluid balances (p < 0.05). However, this effect was only observed in the group of eCPR patients and not in patients with cardiogenic shock. Logistic regression revealed albumin administration as an independent predictor of increased survival (Odds ratio 1.66 (1.11-2.47) [95%-CI], p = 0.013). Yet, only eCPR patients showed a survival benefit from albumin administration compared to the crystalloid group (survival of 29.4% vs. 18.8%, p = 0.024).

CONCLUSION

Early albumin administration in eCPR patients was linked to a significant decline in fluid balance. Moreover, volume therapy with albumin application was an independent predictor for improved survival in eCPR patients.

Oxidative stress and antioxidants in patients with cardiogenic shock complicating acute myocardial infarction

BACKGROUND

Lipid peroxidation and derived oxidized products are being intensively investigated because of their potential to cause injury and because of their pathogenic role in several diseases. The view that an excess of lipid peroxidation products is present and is relevant in the pathogenesis of cardiogenic shock-induced damage has still not received definitive support.

METHODS

To evaluate the extent of lipid peroxidation, the status of enzymatic and nonenzymatic antioxidants in patients with cardiogenic shock that complicate acute myocardial infarction (AMI) and to compare with normal subjects.

RESULTS

Compared with normal subjects, cardiogenic shock patients had higher malondialdehyde, conjugated dienes and reduced activities of erythrocyte antioxidant enzymes such as superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) and lower concentrations of reduced glutathione (GSH) in erythrocyte and in plasma GSH, vitamin C, vitamin E and in beta-carotene.

CONCLUSIONS

Cardiogenic shock is associated with greater than normal lipid peroxidation and with an imbalance in antioxidants' status. These results indicate that low activities of SOD, CAT, GPx and low concentrations of GSH, vitamin C, vitamin E and beta-carotene in the circulation of patients with cardiogenic shock complicating AMI may be due to increased utilization to scavenge lipid peroxides. Decrease in plasma concentrations of GSH, vitamin E and beta-carotene seems to be responsible for the elevation of lipid peroxidation in cardiogenic shock complicating AMI compared with MI.

Prognosis in cardiogenic shock after acute myocardial infarction in the interventional era

OBJECTIVES

The purpose of this study is to describe the outcome in cardiogenic shock treated with aggressive reperfusion therapy and to identify factors predictive of in-hospital and long-term mortality.

BACKGROUND

Cardiogenic shock is the most common cause of death in patients admitted to the coronary care unit. Although studies have reported lower mortality rates in shock treated with angioplasty, few studies have described a cohort of patients with shock who were not selected because they were most likely to benefit from reperfusion therapy.

METHODS

A consecutive series of 200 patients admitted with acute myocardial infarction complicated by cardiogenic shock were studied.

RESULTS

The in-hospital mortality rate was 53%. Variables with significant univariable association with in-hospital death included patency of the infarct-related artery, patient age, lowest cardiac index, highest arteriovenous oxygen difference and left main coronary artery disease. The most important independent predictors of in-hospital death were patency of the infarct-related artery, cardiac index and peak creatine kinase, MB fraction. The mortality rate in patients with patent infarct-related arteries was 33% versus 75% in those with closed arteries and 84% in those in whom arterial patency was unknown. Patients who survived to hospital discharge were followed up for a median of 2 years, with a mortality rate of 18% after 1 year. The best descriptors of the relation between these variables and postdischarge mortality included age, peak creatine kinase, ejection fraction and patency of the infarct-related artery.

CONCLUSIONS

In a large consecutive series of patients with cardiogenic shock with complete follow-up, patency of the infarct-related artery was most strongly associated with in-hospital and long-term mortality. This finding supports an aggressive interventional strategy in patients with cardiogenic shock.

Understanding circulatory shock. Is it hypovolemic, cardiogenic, or vasogenic?

Circulatory shock comprises a group of complex circulatory syndromes that result from a variety of conditions. It alters the function of most organ systems and has very high mortality. Identification of the type of shock (hypovolemic, cardiogenic, vasogenic, or a combination) and optimal treatment are aided by hemodynamic monitoring, including determination of preload, cardiac output, and systemic vascular resistance. Experimental studies and isolation of bioactive substances have improved understanding of the mechanisms involved in shock. Restoration of intravascular volume, cardiac contractility, and vascular tone and control of the underlying septic process when applicable are the basis of current therapy. Close monitoring and support of the affected organ systems in an intensive care environment facilitate recovery. Encouraging results with new treatments indicate improved chances for a satisfactory outcome in patients with circulatory shock.

Rheoreceptors in the carotid sinus of dog

The arterial baroreceptors are known to be sensitive to changes in pressure but there are no known sensors in the cardiovascular system for changes in flow. We tested the hypothesis that changes in flow at constant pressure alter carotid sinus multi-unit nerve activity. In anesthetized dogs with vascularly isolated carotid sinuses, increases in flow at constant pressure resulted in increases in carotid sinus nerve activity in relation to the increase in flow. The increased activity during flow was not caused by an increase in strain of the sinus wall but was directly related to the increase in shear stress (36.6 +/- 11.7% increase in activity per dyne/cm2; 1 dyne = 0.1 MN). The pressure threshold of single baroreceptor units was determined during a slow pressure ramp with and without flow. Flow caused a significant decrease in pressure threshold from 81.1 +/- 6.1 mmHg (1 mmHg = 1.333 x 10(2) Pa) in the absence of flow to 69.3 +/- 5.7 mmHg with flow. We conclude that there are arterial "rheoreceptors" in the carotid sinus that respond to flow at constant pressure and strain. The results with single baroreceptor units indicate also that baroreceptors may be sensitized by increases in flow. Thus, changes in flow per se in addition to changes in arterial pressure may be important determinants of reflex circulatory adjustments.