Görge G, Haude M, Baumgart D, Sack S, Ge J, Leischik R, Erbel R
Abteilung für Kardiologie, Universität (Gesamthochschule) Essen.
Herz. 1994 Dec;19(6):360-70.
Cardiogenic shock in acute myocardial infarction patients is the most common cause of in-hospital death. Various studies showed, that 60 to 100% of patients in cardiogenic shock will die, if no early reperfusion of their coronary artery could be established. The incidence of cardiogenic shock has decreased during the last years, most likely due to early thrombolytic therapy and administration of nitroglycerin. Reasons for cardiogenic shock are either necrosis of 40% or more of the left ventricular wall, right heart infarction, or complications which can be treated by the surgeon, like papillary muscle rupture, ventricular septal defect or rupture of the free ventricular wall. Diagnosis is based on clinical criteria, echocardiography, and on hemodynamic monitoring. The hemodynamic criteria for cardiogenic shock are a cardiac index of < 2.2/l, and an increased wedge pressure of > 18 mm Hg; additionally, diuresis is usually < 20 ml/h. Therapy can be divided into the following categories: a) pharmaceutical interventions to increase cardiac output like vasodilators or positive inotrope drugs; b) mechanical support systems; c) acute interventions with the aim of reperfusion; d) acute surgical interventions addressing complications like papillary muscle rupture, ventricular septal defect or rupture of the free ventricular wall. While steps a) and b) are able to stabilize the hemodynamical situation in patients with cardiogenic shock, they are rarely the definitive treatment. Point c), reperfusion of the coronary artery, can be divided in thrombolysis or acute PTCA. Thrombolysis failed to show a beneficial effect in most studies, either after intravenous or intracoronary application. On contrast, acute PTCA showed to be of great benefit in various studies with a technical success rate of 54 to 100% and a survival rate of patients from 58 to 100%. Thus, emergency PTCA is the treatment of choice in cardiogenic shock. Point d), surgical interventions can be divided in acute bypass grafting, which should be reserved for patients with severe multivessel disease, left main involvement, or failed PTCA. Furthermore, acute heart transplantation is effective, but will be possible in a minority of patients only. The last part of surgically manageable complications are surgery of papillary muscle rupture and ventricular septal defect. Results of early surgery in papillary muscle rupture or ventricular septal defects are much better than delayed interventions. Rupture of the free wall is usually a fatal event. In summary, the most successful therapy of cardiogenic shock is early emergency PTCA.(ABSTRACT TRUNCATED AT 400 WORDS)
急性心肌梗死患者的心源性休克是院内死亡的最常见原因。多项研究表明，如果不能早期实现冠状动脉再灌注，60%至100%的心源性休克患者将会死亡。在过去几年中，心源性休克的发病率有所下降，这很可能归功于早期溶栓治疗和硝酸甘油的使用。心源性休克的原因包括左心室壁40%或更多发生坏死、右心梗死，或可由外科医生治疗的并发症，如乳头肌破裂、室间隔缺损或心室游离壁破裂。诊断基于临床标准、超声心动图和血流动力学监测。心源性休克的血流动力学标准为心脏指数<2.2L，楔压升高>18mmHg；此外，尿量通常<20ml/h。治疗可分为以下几类：a）通过血管扩张剂或正性肌力药物等药物干预增加心输出量；b）机械支持系统；c）旨在实现再灌注的急性干预；d）针对乳头肌破裂、室间隔缺损或心室游离壁破裂等并发症的急性外科干预。虽然步骤a）和b）能够稳定心源性休克患者的血流动力学状况，但它们很少是确定性治疗方法。要点c），冠状动脉再灌注可分为溶栓或急性经皮冠状动脉腔内血管成形术（PTCA）。在大多数研究中，无论是静脉内还是冠状动脉内应用，溶栓均未显示出有益效果。相比之下，急性PTCA在多项研究中显示出巨大益处，技术成功率为54%至100%，患者生存率为58%至100%。因此，急诊PTCA是心源性休克的首选治疗方法。要点d），外科干预可分为急性旁路移植术，应保留给患有严重多支血管病变、左主干受累或PTCA失败的患者。此外，急性心脏移植有效，但仅适用于少数患者。外科可处理并发症的最后一部分是乳头肌破裂和室间隔缺损的手术。乳头肌破裂或室间隔缺损的早期手术结果远优于延迟干预。心室游离壁破裂通常是致命事件。总之，心源性休克最成功的治疗方法是早期急诊PTCA。（摘要截取自400字）
