Abstract
The pharmacological therapy of cardiogenic shock is determined by the underlying pathophysiology. In pump failure, secondary to severe obstructive coronary artery disease with a large compartment of ischemic myocardium at risk, coronary reserve is severely impaired. Any attempt to improve cardiac performance must consider the delicate balance between oxygen supply and requirement. Coronary blood flow is dependent on coronary perfusion pressure. Agents increasing arterial blood pressure improve coronary perfusion, but do not increase cardiac output and, thus, interfere with perfusion of vital organs. Inotropic agents, improving cardiac performance, may increase myocardial oxygen requirements in excess of availability; improvement of peripheral perfusion occurs at cost of a deteriorating pump. Contrarily, in pump failure due to primary myocardial impairment, as myocardiopathy or depression of ventricular function by extracorporal circulation, impairment of energy utilization by the myocardium, of contractility, and of neuro-humoral responses are primary factors. Measures to improve cardiac performance are less limited by considerations of increasing myocardial oxygen requirements. Dobutamine, a relatively selective beta 1 , agonist, and dopamine, a nonselective beta, alpha, and dopaminergic agonist, are the most frequently applied vasoactive agents in the treatment of cardiogenic shock. Their effects are highly dose dependent. Both catecholamines improve cardiac performance and peripheral perfusion. The major differences between the two drugs are related to the effect on heart rate, cardiac filling pressure, and systemic vascular resistance. At clinically tolerated doses, dobutamine is a more potent inotropic agent than dopamine. The decrease in vascular resistance, unloading the left ventricle, is beneficial for the failing heart. Heart rate remains essentially unchanged. In contrast, dopamine increases arterial pressure, left ventricular filling pressure and, at higher doses, heart rate. If blood pressure cannot be maintained by dobutamine, dopamine is preferable. Moreover, the combination of both vasoactive agents has been proven beneficial, supplemented by I-norepinephrine, if necessary. An aggressive approach to unstable angina and complicated myocardial infarction, identification of the patient at high risk for sudden cardiac events, introduction of myocardial preservations during surgery, and improved techniques have contributed to the decreased frequency of cardiogenic shock.
Résumé
Le traitement pharmacologique du choc cardiogénique dépend de la physiopathologie sous-jacente. En cas de défaillance de la fonction pompe, dûe à une coronaropathie obstructive sévère avec une grande zone myocardique ischémique, l'ensemble du système coronarien est profondément altéré. Toute tentative pour améliorer les performances cardiaques doit prendre en compte l'équilibre fragile entre les apports et les besoins d'oxygène. Le débit coronarien dépend de la pression de perfusion coronaire. Les substances qui accroissent la pression artérielle améliorent la perfusion coronaire, mais n'augmentent pas le débit cardiaque et par là même, interfèrent avec la perfusion d'autres organes vitaux. Les substances inotropes, améliorant les performances cardiaques, peuvent accroitrent la demande myocardique en oxygène et ce de façon supérieure à l'apport, l'amélioration de la perfusion périphérique survenant au prix d'une détérioration de la fonction pompe. A l'opposé, pour les défaillances de la fonction pompe dues à des altérations primitives du myocarde, telles que les cardiomyopathies ou les atteintes de la fonction ventriculaire après circulation extra-corporelle, les diminutions d'utilisation d'énergie par le myocarde; diminution de la contractilité et diminution de la réponse neurohumorale, sont les facteurs déterminants. Les moyens pour améliorer les performances cardiaques sont moins limités par l'augmentation des besoins en oxygène du myocarde. La Dobutamine, qui stimule les récepteurs béta-1 de façon relativement sélective et la Dopamine qui stimule de façon non sélective les récepteurs béta, alpha et dopaminergiques, sont les substances vasoactives les plus fréquemment utilisées dans le traitement des chocs cardiogéniques. Leurs effets sont hautement doses-dépendants. Ces deux catécholamines accroissent les performances cardiaques et la perfusion périphérique. La différence principale entre ces deux substances est dûe à leurs effets sur la fréquence cardiaque, les pressions de remplissage et les résistances vasculaires systèmiques. Aux doses d'utilisation clinique, la Dobutamine est plus fortement inotrope que la Dopamine. La diminution des résistances vasculaires, qui diminue le remplissage du ventricule gauche, améliore la défaillance cardiaque. La fréquence cardiaque reste à peu près inchangée. A l'opposé, la Dopamine accroit la pression artérielle, accroit les pressions de remplissage ventriculaire gauche, et à des doses plus élevées accroit la fréquence cardiaque. Si la pression artérielle ne peut être maintenue par la Dobutamine, la Dopamine est préférable. Quoi qu'il en soit, la combinaison de ces deux substances vaso-actives a démontré son efficacité, accrue si nécessaire par la Norepinéphrine. Une attitude thérapeutique active vis-à-vis de l'angor instable et des complications de l'infarctus du myocarde, la détection des malades à haut risque, l'utilisation de la préservation myocardique pendant la chirurgie et l'amélioration des techniques, ont contribué à la diminution du nombre des chocs cardiogéniques.
Resumen
El shock cardiogénico representa un derrumbamiento de la función ventricular y del metabolismo miocárdico. La terapia farmacológica del shock cardiogénico está determinada por la patofisiología subyacente. En la falla de bomba secundaria a severa enfermedad coronaria obstructiva con un gran compartimiento del miocardio isquémico en riesgo, la reserva coronaria se halla severamente afectada. Cualquier intento por mejorar la función cardiaca debe considerar el delicado equilibrio entre la provisión de oxígeno y la demanda. El flujo sanguíneo coronario depende de la presión de perfusión coronaria. Los agentes que aumentan la presión arterial mejoran la perfusión coronaria, pero no aumentan el débito cardiaco y, por lo tanto, interfieren con la perfusión de órganos vitales. Los agentes inotrópicos, al mejorar la función cardiaca, pueden aumentar los requerimientos miocárdicos de oxígeno más allá de la disponibilidad; la mejoría en la perfusión periférica ocurre a expensas de una bomba en deterioro. Por el contrario, en la falla de bomba debida a afección primaria del miocardio, como ocurre en miocardiopatías o en la depresión de la función ventricular por la circulación extracorpórea, el impedimento de la utilización energética por el miocardio, de la contractilidad y de las respuestas neurohumorales, son todos factores primarios. En esta situación las medidas orientadas a mejorar la función cardiaca se encuentran menos limitadas por las consideraciones relativas a los requerimientos miocárdicos de oxígeno. La dobutamina, un agonista beta 1 relativamente selectivo, y la dopamina, un agonista beta no selectivo, alfa y dopaminérgico, son los agentes vasoactivos más frecuentemente utilizados en el tratamiento del shock cardiogénico. Sus efectos son notoriamente dosis-dependientes. Ambas catecolaminas mejoran la función cardiaca y la perfusión periférica. Las diferencias principales entre las dos residen en su efecto sobre la frecuencia cardiaca, la presión de llenamiento y la resistencia vascular sistémica. En las dosis clínicamente tolerables la dobutamina es un agente inotrópico más potente que la dopamina. La disminución en la resistencia vascular, que reduce la carga del ventrículo izquierdo, es beneficiosa para el corazón descompensado. La frecuencia cardiaca se mantiene esencialmente sin cambio. En contraste, la dopamina aumenta la presión arterial, la presión de llenamiento del ventrículo izquierdo y, en dosis mayores, la frecuencia cardiaca. Si la presión arterial no logra ser sostenida con dobutamina, la dopamina es preferible. Por otra parte, la combinación de los dos agentes vasoactivos ha probado ser beneficiosa, suplementada con 1-norepinefrina si necesario. La actitud agresiva ante la angina inestable y el infarto miocárdico complicado, la identificación del paciente con alto riesgo de sufrir alteraciones cardiacas súbitas, la introducción de la preservación miocárdica en el curso de la cirugía y las mejores técnicas de anestesia y cirugía han contribuido a disminuir la frecuencia del shock cardiogénico.
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Mueller, H.S. Inotropic agents in the treatment of cardiogenic shock. World J. Surg. 9, 3–10 (1985). https://doi.org/10.1007/BF01656250
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DOI: https://doi.org/10.1007/BF01656250