Description
Myocardial ischemia is a lack of blood flow getting to your heart muscle. That means your heart muscle isn’t getting enough blood to do what it needs to do. Often, the cause is a collection of fat and cholesterol (plaque) that doesn’t let enough blood go through your coronary arteries. Medicines and surgeries can treat myocardial ischemia. Each year, more than 1 million people in the United States die from myocardial infarction (heart attack). This is due to myocardial ischemia, a lack of blood flow and oxygen to your heart muscle.
Summary Listen
- Cardiogenic shock, often stemming from acute myocardial infarction, presents with systolic or diastolic dysfunction. Diastolic dysfunction manifests as pulmonary congestion and hypoxemia, exacerbating coronary obstruction. Systolic dysfunction leads to reduced cardiac output, anaerobic metabolism, and lactate production, hindering oxygen delivery to tissues. The cardiovascular system's ability to transport oxygen is compromised in cardiogenic shock due to low cardiac output.
- Treatment strategies involve early identification and classification of shock, stabilization, and definitive intervention in a hemodynamics laboratory or operating room. Hemodynamic assessment is crucial for addressing preload, contractility, and afterload aberrations. A multidisciplinary team, including a shock team, plays a vital role in patient management. Timely transport to a center equipped for coronary intervention, monitoring, and circulatory support is critical.
- Phenotypes in cardiogenic shock are related to the trilogy of shock and severity. Congestion, edema, and venous congestion increase the risk of developing cardiogenic shock. Identifying shock stage, recognizing hemodynamic impairments, and managing metabolic arrangements are essential. Vasopressor support should be administered carefully due to potential myocardial injury.
- The Sky classification categorizes cardiogenic shock from A to E, influencing the timing of hemodynamic monitoring. Hemodynamic tools alone do not offer treatment, and close monitoring should coincide with interventions. Stratification and treatment must accompany hemodynamic monitoring. The timing of hemodynamic monitoring is critical, with delayed monitoring offering limited benefit.
- Pulmonary artery catheters and calibrated pulse pressure analysis are primarily used in the ICU. Outside the ICU, echocardiography and Doppler assessments are preferred for identifying hemodynamic derangements. Pulmonary artery catheters offer continuous measurement of oxygen saturation, end-diastolic volume, and right ventricular ejection pressure.
- Shock teams utilize pulmonary artery catheters in conjunction with perfusion variables like lactate and arterial blood gases. Inter-aortic balloon pumps and inotropes are employed based on cardiac index. The historical Forests and colleagues classification established cutoffs for cardiac index and pulmonary capillary wedge pressure in diagnosing cardiogenic shock.
- The use of pulmonary artery catheters often occurs after stage C of the Sky classification. Delayed catheter placement diminishes potential benefits. While studies show varying rates of pulmonary artery catheter use, there's a trend toward increased utilization. Pulmonary artery catheters alone do not improve mortality outcomes. Transpulmonary thermodilution shows correlation with pulmonary artery catheter measurements.
- Echocardiography is crucial for assessing contractility, cavity size, and pulmonary artery pressure. Cardiac power output correlates with mortality, with values below 0.6 indicating a higher risk. Mitral regurgitation and ventricular septal defects can complicate acute myocardial infarction and require specific management strategies.
- Phenotypes reflect disease intensity and treatment delays. Understanding indications, interpretations, and therapeutic plans is essential for effective hemodynamic monitoring. No monitoring tool reduces mortality. Timely hemodynamic monitoring during stage C of the Sky classification is critical for improving patient outcomes.
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About the Speakers
Dr Rushyendra
European Diploma in Critical care ,UK HOD , Dept of critical care, KIIMS Hospital
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