Step 2 early definition of coronary anatomy

This is the pivotal step in the management of cardiogenic shock resulting from predominant ischaemic pump failure. Patients in a community hospital setting should be emer-gently transferred/airlifted to an experienced designated regional tertiary care facility. The referring and accepting physician as well as the critical care transport team should be in constant communication to avoid delays in cardiac catheteri-sation. Prophylactic IABP placement is recommended before transfer and otherwise before angiography; radiocontrast use should be minimised. Early reversal of hypotension with IABP support serves as an excellent prognostic marker for survival, but those who do or do not respond well to IABP both derive benefit from early revascularisation. If a high quality echocar-diogram has already been performed, a ventriculogram need not be repeated. Shock is characterised by a high incidence of triple vessel disease, left main disease, and impaired left ventricular function.24 The mean (SD) left ventricular ejection fraction for patients in the SHOCK trial and registry was 29 (11)% and 34 (14)%, respectively. The extent of ventricular dysfunction and haemodynamic instability should be correlated with coronary anatomy. An isolated circumflex lesion or a right coronary lesion should rarely manifest as shock in the absence of right ventricular infarction, left ventricular underfilling, bradyarrhythmia or prior MI or cardiomyopathy. In situations like this it is important for the clinician to immediately consider and exclude mechanical and other aetiologies of cardiogenic shock.

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