Cardiogenic hypotension

Management objectives include limiting further myocardial injury (in the presence of acute infarction), restoring myocardial pump function and thus improving cardiac output, and determining whether any mechanical defect amenable to an invasive intervention exists (e.g. valve replacement, angioplasty, or surgical revascularization).

Intubation and assisted ventilation are early considerations as such patients may die from respiratory fatigue because of the imbalance between O 2 supply to the respiratory muscles and the increased needs associated with a greater respiratory workload.

Circulatory management is facilitated by reviewing the patient according to the Forrester classification, which uses the presence of pulmonary congestion (both radiographic and auscultatory) and peripheral hypoperfusion (as diagnosed by decreased skin temperature, confusion, or oliguria in conjunction with either hypotension or tachycardia) (T.a.b.le...Z). This approach conveniently provides information about prognosis and directs early management ( Fig, 2). Inherent in this approach is the use of the pulmonary artery catheter to measure left ventricular filling pressures and cardiac output. Although pulmonary artery wedge pressure is not a direct measure of cardiac preload, it does provide sufficient information to allow intelligent use of fluid in the management of cardiogenic hypotension.

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Table 7 Correlative classification of clinical and hemodynamic function after acute myocardial infarction

Fig. 2 Management of the patient with inadequate oxygen delivery. PTCA, percutaneous transluminal coronary angioplasty.

Other key issues are pain relief, arrhythmia management, and treatment of pulmonary edema. Pain relief, for example by repetitive intravenous administration of small doses of morphine, will be accompanied by a reduction of myocardial O2 consumption because endogenous catecholamine secretion will be reduced. Correcting atrial arrhythmias may improve ventricular filling (with restoration of an atrial kick), thereby augmenting cardiac output. Correcting ventricular arrhythmias will also restore the cardiac output reserve. Primary issues to consider in the presence of arrhythmias include electrolyte abnormalities, pain, or arterial deoxygenation. Pacing may need to be considered for significant bradycardia. Continuous infusion of vasodilators plus diuretics may be needed for pulmonary edema.

Percutaneous insertion of an intra-aortic balloon counterpulsation may be considered for refractory cardiogenic hypotension to improve coronary blood flow and decrease left ventricular impedance (and thus afterload). Surgical intervention such as implantation of a ventricular assist device for bridging until a possible heart transplantation is only experimental at this stage. Mechanical abnormalities should also be excluded. Acute revascularization (thrombolysis, angioplasty, coronary artery bypass grafting) may be indicated. Other correctable lesions include acute valvular insufficiency (particularly mitral), ventricular rupture, and tamponade.

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