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Kardiogener Schock

Aktuelle Evidenz

Cardiogenic shock

Current evidence

  • CME
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Zusammenfassung

In diesem Beitrag werden die Pathophysiologie, die Inzidenz, das Überleben und die Behandlungsoptionen von Patienten mit kardiogenem Schock im Rahmen eines akuten Myokardinfarkts dargelegt. Die Schockspirale aus Blutdruckabfall in Folge von Linksherzversagen nach Herzinfarkt, konsekutiver Vasokonstriktion, paradoxer Vasodilatation beim SIRS („systemic inflammation response syndrome“) ist ein Circulus vitiosus, wenn er nicht unterbrochen wird. In der Therapie wird deshalb ein wesentliches Augenmerk auf die Evidenz in randomisierten Studien und die derzeitigen Leitlinienempfehlungen gelegt. Hier wird die Frage der „culprit lesion“ vs. „komplette Revaskularisation“ noch unterschiedlich bewertet. Bei der medikamentösen Therapie kommen neben Acetylsalicylsäure (ASS) und Heparin vermehrt Prasugrel oder Ticagrelor zum Einsatz. Bei den Inotropika bleibt Dobutamin erste Wahl, bei den Vasopressoren Noradrenalin. Der Kalzium-Sensitizer Levosimendan hat bei akuter Herzinsuffizienz die in ihn gesetzten Hoffnungen in randomisierten Studien nicht bestätigen können. Die Verwendung der intraaortalen Ballonpumpe (IABP) als mechanische Kreislaufunterstützung wurde auf eine Klasse-III-Empfehlung herabgestuft. Die Verwendung von perkutan implantierbaren mechanischen Kreislaufunterstützungssystemen zeigte wegen der erhöhten Blutungskomplikationen in den wenigen bisher durchgeführten randomisierten Studien keinen Überlebensvorteil, auch nicht im Vergleich zur IABP.

Abstract

This CME article addresses the pathophysiology, incidence, current survival outcome and treatment options for patients with cardiogenic shock as a complication of acute myocardial infarction. The shock spiral of left heart failure due to cardiac infarction, subsequent vasoconstriction and paradoxical vasodilation due to the systemic inflammation response syndrome (SIRS) is a vicious circle which must be interrupted. Treatment focuses on the evidence from randomized clinical trials and the current guideline recommendations. With respect to interventional and surgical treatment the question of culprit lesion vs. complete revascularization is still unsolved. For medicinal treatment acetylsalicylic acid (ASA) and heparin are more often supplemented with prasugrel and ticagrelor. In the case of inotropes, dobutamine remains the first-line treatment option and for vasopressors norepinephrine. The calcium sensitizer levosimendan has not provided the hoped for superiority over conventional treatment in randomized trials. The use of intra-aortic balloon pumps (IABP) is no longer recommended as circulatory support in acute heart failure (reduced to class III). The use of percutaneous implantable mechanical circulatory support devices has not shown a survival benefit in the few randomized trials carried out so far even when compared with IABP, due to increased bleeding complications.

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Authors and Affiliations

  1. Herzzentrum, Klinik für Innere Medizin/Kardiologie, Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland

    H. Thiele

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Interessenkonflikt

H. Thiele gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

CME-Fragebogen

CME-Fragebogen

Bei der Pathophysiologie im kardiogenen Schock spielt welcher der folgenden Faktoren keine wesentliche Rolle?

Diastolische Dysfunktion

Systolische Dysfunktion

Euler-Liljestrand-Mechanismus

Inflammation

Vasodilatation

Bevorzugter Zugangsweg bei der PCI auch im kardiogenen Schock bei geübten Untersuchern ist …

A. brachialis.

A. femoralis.

A. ulnaris.

Zugangsweg nach Sones.

A. radialis.

Bevorzugter Vasokonstriktor im kardiogenen Schock nach den Leitlinien ist …

Adrenalin.

Dopamin.

Theodrenalin.

Noradrenalin.

Vasopressin.

Wodurch ist die Wirkung von Antiplättchensubstanzen im kardiogenen Schock nicht beeinträchtigt?

Hypothermie

UV-Licht

Opiatgabe

Reduzierter Kreislauf

Reduzierte Stoffwechselfunktion

Nach aktuellen Registerdaten liegt die Mortalität im kardiogenen Schock als Folge eines Myokardinfarkts zwischen …

70 und 80 %

60 und 70 %

50 und 60 %

40 und 50 %

30 und 40 %

Was ist keine typische Ursache eines kardiogenen Schocks nach Myokardinfarkt?

Mitralklappeninsuffizienz

Ventrikelseptumdefekt

Linksherzversagen

Rechtsherzversagen

Vorhofthrombus

Was ist die häufigste Ursache für einen kardiogenen Schock nach Myokardinfarkt?

Ventrikelseptumdefekt

Ventrikelruptur

Mitralinsuffizienz

Rechtsherzversagen

Linksherzversagen

Wie hoch ist die Inzidenz einer Mehrgefäß-KHK bei kardiogenem Schock mit Myokardinfarkt?

70–80 %

60–70 %

50–60 %

40–50 %

30–40 %

Was ist kein typisches Kriterium für die Definition eines kardiogenen Schocks?

Systolischer Blutdruck < 90 mm Hg

Laktat > 2 mmol/l

Lungenödem

Oligurie

Bradykardie

Nach einer aktuellen Metaanalyse lässt sich welcher der folgenden Parameter durch mechanische Kreislaufunterstützungssysteme positiv beeinflussen?

Arterielles Laktat

PCWP

„Cardiac index“

Mortalität

Mikrozirkulation

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Thiele, H. Kardiogener Schock. Herz 42, 795–806 (2017). https://doi.org/10.1007/s00059-017-4619-5

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