《与梗塞相关的心原性休克的诊断、监测和治疗——德国-奥地利 S3 指南》
Infarction-Related Cardiogenic Shock- Diagnosis, Monitoring and Therapy–A German-Austrian S3 Guideline.
机构信息
* Guideline group see eBox 1; Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany; Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany; Department of Cardiology, Clinic Ottakring, Vienna Healthcare Group, Vienna, Austria; Department of Cardiology, University of Leipzig, Heart Center Leipzig, Leipzig, Germany; Department of Anesthesiology, University Hospital, LMU, Munich, Germany; Internists at the Maxplatz, Traunstein/Affiliate Cardiology Traunstein, Traunstein, Germany.
出版信息
Dtsch Arztebl Int. 2021 Feb 12;118(6):88-95. doi: 10.3238/arztebl.m2021.0012.
BACKGROUND
The second edition of the German-Austrian S3 guideline contains updated evidence-based recommendations for the treatment of patients with infarction-related cardiogenic shock (ICS), whose mortality is several times higher than that of patients with a hemodynamically stable myocardial infarction (1).
METHODS
In five consensus conferences, the experts developed 95 recommendations-including two statements-and seven algorithms with concrete instructions.
RESULTS
Recanalization of the coronary vessel whose occlusion led to the infarction is crucial for the survival of patients with ICS. The recommended method of choice is primary percutaneous coronary intervention (pPCI) with the implantation of a drug-eluting stent (DES). If multiple coronary vessels are diseased, only the infarct artery (the "culprit lesion") should be stented at first. For cardiovascular pharmacotherapy-primarily with dobutamine and norepinephrine-the recommended hemodynamic target range for mean arterial blood pressure is 65-75 mmHg, with a cardiac index (CI) above 2.2 L/min/m2. For optimal treatment in intensive care, recommendations are given regarding the type of ventilation (invasive rather than non-invasive, lungprotective), nutrition (no nutritional intake in uncontrolled shock, no glutamine supplementation), thromboembolism prophylaxis (intravenous heparin rather than subcutaneous prophylaxis), und further topics. In case of pump failure, an intra-aortic balloon pump is not recommended; temporary mechanical support systems (Impella pumps, veno-arterial extracorporeal membrane oxygenation [VA-ECMO], and others) are hemodynamically more effective, but have not yet been convincingly shown to improve survival.
CONCLUSION
Combined cardiological and intensive-care treatment is crucial for the survival of patients with ICS. Coronary treatment for ICS seems to have little potential for further improvement, while intensive-care methods can still be optimized.
背景
德国-奥地利 S3 指南第二版包含了更新的基于证据的建议，用于治疗与梗塞相关的心源性休克（ICS）患者，其死亡率比血流动力学稳定的心肌梗死（1）患者高几倍。
方法
在五次共识会议上，专家们制定了 95 条建议，包括两条声明和七个带有具体说明的算法。
结果
导致梗塞的冠状动脉再通对于 ICS 患者的存活至关重要。推荐的首选方法是经皮冠状动脉介入治疗（pPCI），并植入药物洗脱支架（DES）。如果有多条冠状动脉病变，应首先仅对梗塞动脉（“罪犯病变”）进行支架置入。对于心血管药物治疗 - 主要是多巴酚丁胺和去甲肾上腺素 - 推荐的平均动脉血压目标范围为 65-75mmHg，心指数（CI）大于 2.2L/min/m2。为了在重症监护中获得最佳治疗，给出了关于通气类型（侵入性而非非侵入性，肺保护性）、营养（不受控制的休克时无营养摄入，不补充谷氨酰胺）、血栓栓塞预防（静脉肝素而非皮下预防）等方面的建议。在泵衰竭的情况下，不推荐使用主动脉内球囊泵；临时机械支持系统（Impella 泵、静脉-动脉体外膜肺氧合[VA-ECMO]等）在血液动力学上更有效，但尚未令人信服地证明能提高生存率。
结论
联合心脏科和重症监护治疗对 ICS 患者的存活至关重要。ICS 的冠状动脉治疗似乎没有进一步改善的潜力，而重症监护方法仍可以优化。
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