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Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie

Infarct-related cardiogenic shock – Diagnosis, monitoring and therapy

  • Übersicht
  • Published:
Intensivmedizin und Notfallmedizin

Zusammenfassung

Bei Patienten mit ST-Streckenhebungsinfarkt (STEMI) und Nicht-ST-Streckenhebungsinfarkt (NSTEMI) kommt es in ca 6–10% der Fälle im Krankenhaus zu einem kardiogenen Schock. In den letzten Jahren scheint die Inzidenz aufgrund der invasiven Diagnostik und Therapie nach Myokardinfarkt sich leicht zu reduzieren. Neben der ischämieinduzierten Pumpfunktionsstörung kommt der Inflammation - vermittet durch Leukozyten- und Cytokinaktivierung - eine wichtige Rolle bei der Pathogenese und Prognose des kardiogenen Schocks zu.

Wichtig ist die frühzeitige Diagnose, um die schnelle Revaskularisation mittels PCI und Stent im Rahmen des kardiogenen Schocks einzuleiten und so eine deutliche Verbesserung des Überlebens zu erreichen. Mechanische Unterstützung und medikamentöse Therapien erlauben auch bei Hochrisikopatienten eine sichere und effektive Behandung. Mechanische und pharmakologische Unterstützung sind notwendig, um die Perfusion des Myokards und der Organe aufrecht zu erhalten. Als medikamentöse Therapie bei infarktbedingtem kardiogenem Schock hat sich Dobutamin als Inotropikum und Noradrenalin als Vasopressor etabliert. Zur weiteren Unterstützung liegen Daten zu Levosimendan und Erfahrungen mit PDE-IV-Hemmern vor. Dopamin und Adrenalin stehen als sekundäre Alternativen zur Verfügung. Neue Ansätze wie NOS Inhibitoren konnte in klinischen Studien keinen Wirkvorteil belegen. Die pharmakologische Therapie wird durch mechanische Unterstützungssysteme wie IABP, Impella oder ECMO ergänzt. Wichtig ist im Verlauf, durch organprotektive Massnahmen die Entstehung weiterer Organdysfunktionen (Niere, Leber, Lunge ua.) zu verhindern. Die Mehrzahl der Überlebenden des kardiogenen Schocks haben langfristig nur eine geringe funktionelle kardiale Einschränkungen, gleich bedeutend mit einer passageren Schädigungskomponente (Stunning, Inflammation), was die Sinnhaftigkeit einer schnellen Kreislauf-unterstützenden Therapie unterstreicht.

Abstract

In patients with STEMI or NSTEMI, cardiogenic shock will occur in approximately 6–10% of cases within the hospital. Mortality rate is still high (50–70%). However, due to early and aggressive invasive treatment of ACS patients, the incidence of cardiogenic shock is declining. Beside ischemic injury, inflammation due to leukocyte and cytokine activation play an important role in the pathogenesis and prognosis of cardiogenic shock patients.

Important is the early diagnosis of cardiogenic shock to initiate revascularization procedures with PCI and stents, which have shown short- and long-term improvement in survival. Currently, mechanical support (IABP) and drug therapy (dobutamine, norepinephrine) are necessary to stabilize myocardial and organ perfusion in high-risk patients. Firstline inotropic support can be archived with dobutamine and norepinephrine for vasopressor support. Recently, promising data exist supporting treatment with levosimendan in favor of PDE inhibitors for inotropic support in cardiogenic shock patients. Dopamine and epinephrine are second line alternatives. No therapeutic benefit could be demonstrated when using novel compounds like NOS inhibitors in CS patients. Promising effects were observed with mechanical support with rotary pumps like Impella or ECMO but need further study. Other organ functions like liver, kidney or lung have to be monitored continuously and protective measures should be used.

The majority of cardiogenic shock survivors have later only slightly decreased LV function, indicating short lasting causative injuries like inflammation or stunning. This concept supports circulatory support to overcome injury.

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Abbreviations

ACS:

Akutes Koronarsyndrom

CPI/CPO:

Cardiac Power Index/Cardiac Power Output

HI:

Herzindex

IABP:

Intraaortale Ballonpumpe

IRA:

Infarkt-bezogene Arterie („Infarct related artery“)

MI:

Myokardinfarkt

MODS:

Multiples Organ-Dysfunktionssyndrom

NPN:

Nitroprussid-Natrium

NSTEMI:

Non-ST-Strecken-Elevations-Myokardinfarkt

PAK:

Pulmonalarterienkatheter

PAP:

Pulmonalarterieller Mitteldruck

PAOP:

Pulmonalarterieller Okklusionsdruck (pulmonalkapillarer „Wedge“-Druck, PCWP)

PCI:

Perkutane Koronarintervention („Percutaneous coronary intervention“)

STEMI:

ST-Strecken-Elevations-Myokardinfarkt („ST-elevation myocardial infarction“)

SVR:

Systemischer Gefäßwiderstand („Systemic vascular resistance“)

SvO2 :

Gemischtvenöse O2-Sättigung

TVR:

Revaskularisierung des Infarkt-Koronargefäßes („Target vessel revascularisation“)

ZVD:

Zentraler Venendruck

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  1. Klinikum der Martin-Luther-Universität, Universitätsklinik und Poliklinik für Innere Medizin III Universitätsklinikum Halle(Saale) der Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube Str. 40, 06097, Halle Saale, Deutschland

    Michael Buerke

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  1. Michael Buerke
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  2. Martin Russ
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Correspondence to Michael Buerke.

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Implikationen für die Intensiv- und Notfallmedizin

Herausgegeben von H.-J. Trappe [Herne]

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Buerke, M., Russ, M., Prondzinsky, R. et al. Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie. Intensivmed 46, 132–145 (2009). https://doi.org/10.1007/s00390-009-0037-0

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