Principles and Management of Heart Failure and Cardiogenic Shock

Abstract

Acute heart failure (HF) is responsible for more than one million hospitalizations annually in both the United States and Europe. Although the outcomes for ambulatory patients with HF have improved with the discovery of evidence-based therapies, hospitalized patients continue to experience high post-discharge mortality and readmission rates. Left ventricular (LV) failure can be divided into systolic and diastolic dysfunction. The former is characterized by a reduced ejection fraction and an enlarged LV chamber, the latter by an increased resistance to filling with increased filling pressures. Acute heart failure and cardiogenic shock secondary to a valvulopathy require early identification to guide management. Left-sided valvulopathies are most common, and these can then progress to cause acute heart failure or cardiogenic shock. In developed countries, aortic stenosis is the most likely cause, followed by mitral regurgitation, aortic regurgitation, and then mitral stenosis. Although there is some variability in the definition of cardiogenic shock used in different clinical trials, it can be roughly defined as a state of end-organ hypoperfusion due to cardiac failure. Mortality after cardiogenic shock remains high despite advances in mechanical support, with mortality rates around 35–40% and no intervention apart from culprit vessel revascularization for patients with myocardial infarction demonstrating a survival benefit.