Cardiogenic shock

Overview

Cardiogenic shock is a life-threatening condition in which your heart suddenly can't pump enough blood to meet your body's needs. The condition is most often caused by a severe heart attack, but not everyone who has a heart attack has cardiogenic shock.

Cardiogenic shock is rare. It's often deadly if not treated immediately. When treated immediately, about half the people who develop the condition survive.

Symptoms

Cardiogenic shock signs and symptoms include:

• Rapid breathing
• Severe shortness of breath
• Sudden, rapid heartbeat (tachycardia)
• Loss of consciousness
• Weak pulse
• Low blood pressure (hypotension)
• Sweating
• Pale skin
• Cold hands or feet
• Urinating less than normal or not at all

Symptoms of a heart attack

Because cardiogenic shock usually occurs in people who are having a severe heart attack, it's important to know the signs and symptoms of a heart attack. These include:

• Pressure, fullness or a squeezing pain in the center of your chest that lasts for more than a few minutes
• Pain spreading to your shoulder, one or both of your arms, your back, or even your teeth and jaw
• Increasing episodes of chest pain
• Shortness of breath
• Sweating
• Lightheadedness or sudden dizziness
• Nausea and vomiting

Seek medical attention quickly when having these signs or symptoms to decrease your risk of developing cardiogenic shock.

When to see a doctor

Getting heart attack treatment quickly improves your chance of survival and reduces damage to your heart. If you're having symptoms of a heart attack, call 911 or other emergency medical services for help. If you don't have access to emergency medical services, have someone drive you to the nearest hospital. Don't drive yourself.

Causes

In most cases, a lack of oxygen to your heart, usually from a heart attack, damages its main pumping chamber (left ventricle). Without oxygen-rich blood flowing to that area of your heart, the heart muscle can weaken and go into cardiogenic shock.

Rarely, damage to your heart's right ventricle, which sends blood to your lungs to get oxygen, leads to cardiogenic shock.

Other possible causes of cardiogenic shock include:

• Inflammation of the heart muscle (myocarditis)
• Infection of the heart valves (endocarditis)
• Weakened heart from any cause
• Drug overdoses or poisoning with substances that can affect your heart's pumping ability

Risk factors

If you have a heart attack, your risk of developing cardiogenic shock increases if you:

• Are older
• Have a history of heart failure or heart attack
• Have blockages (coronary artery disease) in several of your heart's main arteries
• Have diabetes or high blood pressure
• Are female

Complications

If not treated immediately, cardiogenic shock can lead to death. Another serious complication is damage to your liver, kidneys or other organs from lack of oxygen, which can be permanent.

Prevention

The best way to prevent cardiogenic shock is to make lifestyle changes to keep your heart healthy and your blood pressure in check.

• Don't smoke, and avoid secondhand smoke. If you smoke, the best way to reduce your heart attack risk is to quit.
• Maintain a healthy weight. Being overweight contributes to other risk factors for heart attack and cardiogenic shock, such as high blood pressure, cardiovascular disease and diabetes. Losing just 10 pounds (4.5 kilograms) can lower blood pressure and improve cholesterol levels.
• Eat less cholesterol and saturated fat. Limiting these, especially saturated fat, can reduce your risk of heart disease. Avoid trans fats.
• Use less salt. Too much salt (sodium) leads to fluid buildup in the body, which can strain the heart. Aim for less than 2,300 milligrams (mg) a day of sodium. Salt can be found in many canned and processed goods, so it's a good idea to check food labels.
• Cut back on sugar. This will help you avoid nutrient-poor calories and help you maintain a healthy weight.
• Limit alcohol. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and up to two drinks a day for men.
• Exercise regularly. Exercise can lower your blood pressure and improve the overall health of your blood vessels and heart. Get at least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity a week, or a combination of moderate and vigorous activity. It's recommended to spread out this exercise during the course of a week. Greater amounts of exercise will provide even greater health benefits.

If you have a heart attack, quick action can help prevent cardiogenic shock. Seek emergency medical help if you think you're having a heart attack.

Diagnosis

Cardiogenic shock is usually diagnosed in an emergency setting. Doctors will check for signs and symptoms of shock, and will then perform tests to find the cause. Tests might include:

• Blood pressure measurement. People in shock have very low blood pressure.
• Electrocardiogram (ECG or EKG). This quick, noninvasive test records the electrical activity of your heart using electrodes attached to your skin. If you have damaged heart muscle or fluid buildup around your heart, the heart won't send electrical signals normally.
• Chest X-ray. A chest X-ray shows the size and shape of your heart and whether there's fluid in your lungs.
• Blood tests. You'll have blood drawn to check for organ damage, infection and heart attack. An arterial blood gas test might be done to measure oxygen in your blood.
• Echocardiogram. Sound waves produce an image of your heart. This test can help identify damage from a heart attack.
• Cardiac catheterization (angiogram). This test can reveal blocked or narrowed arteries. A doctor inserts a long, thin tube (catheter) through an artery in your leg or wrist and guides it to your heart. Dye flows through the catheter, making your arteries more easily seen on X-ray.

Treatment

Cardiogenic shock treatment focuses on reducing the damage from lack of oxygen to your heart muscle and other organs.

Emergency life support

Most people who have cardiogenic shock need extra oxygen. If necessary, you'll be connected to a breathing machine (ventilator). You'll receive medications and fluid through an IV line in your arm.

Medications

Fluids and plasma are given through an IV. Medications to treat cardiogenic shock are given to increase your heart's pumping ability and reduce the risk of blood clots.

• Vasopressors. These medications are used to treat low blood pressure. They include dopamine, epinephrine (Adrenaline, Auvi-Q), norepinephrine (Levophed) and others.
• Inotropic agents. These medications, which help improve the pumping function of the heart, may be given until other treatments start to work. They include dobutamine, dopamine and milrinone.
• Aspirin. Aspirin is usually given immediately to reduce blood clotting and keep blood moving through a narrowed artery. Take an aspirin yourself while waiting for help to arrive only if your doctor has previously told you to do so for symptoms of a heart attack.
• Antiplatelet medication. Emergency room doctors might give you drugs similar to aspirin to help prevent new clots from forming. These medications include clopidogrel (Plavix), tirofiban (Aggrastat) and eptifibatide (Integrilin).
• Other blood-thinning medications. You'll likely be given other medications, such as heparin, to make your blood less likely to form clots. IV or injectable heparin usually is given during the first few days after a heart attack.

Surgeries and other procedures

Medical procedures to treat cardiogenic shock usually focus on restoring blood flow through your heart. They include:

• Angioplasty and stenting. If a blockage is found during a cardiac catheterization, your doctor can insert a long, thin tube (catheter) equipped with a special balloon through an artery, usually in your leg, to a blocked artery in your heart. Once in position, the balloon is briefly inflated to open the blockage.

  A metal mesh stent might be inserted into the artery to keep it open over time. In most cases, you doctor will place a stent coated with a slow-releasing medication to help keep your artery open.

• Balloon pump. Your doctor inserts a balloon pump in the main artery off of your heart (aorta). The pump inflates and deflates within the aorta, helping blood flow and taking some of the workload off your heart.
• Extracorporeal membrane oxygenation (ECMO). ECMQ helps improve blood flow and supplies oxygen to the body. Blood is pumped outside of your body to a heart-lung machine that removes carbon dioxide and sends oxygen-filled blood back to tissues in the body.

If medications and other procedures don't work to treat cardiogenic shock, your doctor might recommend surgery.

• Coronary artery bypass surgery. This surgery uses a healthy blood vessel in your leg, arm or chest to create a new pathway for blood so it can flow around a blocked or narrowed artery. Your doctor might suggest this surgery after your heart has had time to recover from your heart attack. Occasionally, bypass surgery is done as an emergency treatment.
• Surgery to repair an injury to your heart. Sometimes an injury, such as a tear in one of your heart's chambers or a damaged heart valve, can cause cardiogenic shock. Surgery might correct the problem.
• Ventricular assist device (VAD). A mechanical device can be implanted into the abdomen and attached to the heart to help it pump. A VAD might extend and improve the lives of some people with end-stage heart failure who are waiting for new hearts or aren't able to have a heart transplant.
• Heart transplant. If your heart is so damaged that no other treatments work, a heart transplant may be a last resort.