Cardiogenic shock

This condition, which is defined by hypotension, poor peripheral circulation, and oliguria, should be distinguished from the autonomic reflex vagal overactivity described above. True cardiogenic shock carries a high mortality (60-80 per cent) and should be investigated vigorously (echocardiogram) to exclude a surgical cause. If none is found, urgent revascularization should be considered. This is obviously only available in tertiary centers. In the usual coronary care unit thrombolysis should be considered, despite the often stated (but mistaken) belief that thrombolysis is ineffective. Trials show that thrombolysis reduces absolute mortality substantially, particularly with streptokinase (which because of its own hypotensive action in patients with normal blood pressure is often mistakenly withheld).

Surgical causes include mitral regurgitation due to chordal rupture, or cardiac rupture from the left to the right ventricle, or the left ventricle to the pericardial sac. Urgent intervention can be life saving; with tamponade, and hemopericardium seen on the echocardiogram, urgent pericardiocentesis is worth trying.

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