An uncommon manifestation of shock: Takotsubo syndrome

Appropriateness of Fluid Therapy in Cardiogenic Shock Management: A Systematic Review of Current Evidence

Fluid therapy plays a pivotal role in maintaining tissue perfusion during the management of cardiogenic shock. Nevertheless, its application in this context is contentious, necessitating a balance between achieving adequate volume and avoiding fluid overload. This systematic review aimed to assess the outcomes of fluid therapy in cardiogenic shock. This review encompasses 11 studies involving 406 participants. Although some studies reported hemodynamic improvements following fluid administration, others presented contrasting findings. Studies that did not highlight the benefits of fluid therapy typically involved patients with unique comorbidities requiring specific etiology-based medical treatments. The most prevalent cause of cardiogenic shock, acute coronary syndrome, exhibited varying responses to fluid therapy based on the infarct location. In conclusion, fluid therapy plays a crucial role in cardiogenic shock management but necessitates integration into an appropriate treatment strategy, accounting for individual circumstances, comorbidities, and etiology. Further research is imperative to amass additional evidence regarding this issue.

Takotsubo Syndrome: Finally Emerging From the Shadows?

It is now 30 years since Japanese investigators first described Takotsubo Syndrome (TTS) as a disorder occurring mainly in ageing women, ascribing it to the impact of multivessel coronary artery spasm. During the intervening period, it has become clear that TTS involves relatively transient vascular injury, followed by prolonged myocardial inflammatory and eventually fibrotic changes. Hence symptomatic recovery is generally slow, currently an under-recognised issue. It appears that TTS is induced by aberrant post-β₂-adrenoceptor signalling in the setting of "surge" release of catecholamines. Resultant activation of nitric oxide synthases and increased inflammatory vascular permeation lead to prolonged myocardial infiltration with macrophages and associated oedema formation. Initially, the diagnosis of TTS was made via exclusion of relevant coronary artery stenoses, plus the presence of regional left ventricular hypokinesis. However, detection of extensive myocardial oedema on cardiac MRI imaging offers a specific basis for diagnosis. No adequate methods are yet available for definitive diagnosis of TTS at hospital presentation. Other major challenges remaining in this area include understanding of the recently demonstrated association between TTS and antecedent cancer, the development of effective treatments to reduce risk of short-term (generally due to shock) and long-term mortality, and also to accelerate symptomatic recovery.