The document discusses strategies to improve the prognosis of cardiogenic shock. It presents a case report of a patient who developed cardiogenic shock due to influenza and was successfully treated with inotropes, extracorporeal membrane oxygenation (ECMO), and levosimendan. It emphasizes treating the underlying heart condition, correcting fluid deficits, using inotropes cautiously and only in cardiogenic shock while anticipating adverse effects, choosing reasonable hemodynamic targets, and minimizing inotrope doses. ECMO is suggested as a bridge to decision-making, transplantation, or recovery. Overall, the document provides guidance on optimizing hemodynamics, fluid management, inotrope use, and considering technologies like ECMO

1. CARDIOGENIC SHOCK- HOW CAN WE
IMPROVE THE PROGNOSIS
VASOACTIVE DRUGS
Alain Rudiger, MD
University Hospital Zurich, Switzerland
Heart Failure Meeting of the ESC
Sevilla, May 25th 2015

2. Conflict of interests
Honoraria were received from:
•AOP Orphan (esmolol, vernakalant) for lectures
•BAXTER (esmolol) for expert meetings and lectures
•NOVARTIS (human relaxin-2) for advisory board meetings
•ORION (levosimendan) for expert meetings

3. Case report
• 33-year old woman
• 1-week history of common cold, cough, fever (39°C), diarrhoea and
vomiting
• 2-day history of fatigue, weakness and dyspnoea
• Co-morbidity: anxiety disorder

4. Case report
On admission:
•Somnolent
•Cold periphery, mottled skin
•BP 75/35 mmHg, HR 130 /min
•RR 30 /min

5. Case report

6. Case report

7. Case report

8. Case report

9. Case report
Echocardiography:
•Pericardial tamponade with RV collapse
After drainage:
•Severely impaired LV ejection fraction (28%) with hypokinesia basal
and midventricular, apical akinesia (Takotsubo-like)

10. Case report
Coronary angiography:
•No coronary artery disease
•Biopsies taken for histology
Serology
•Positive for influenza type B

11. Case report
Management:
•Drainage of pericardial effusion
•Start with inotropes (milrinone up to 20 mcg/min)
•MAP goal >55 mmHg, no noradrenaline required
Improvement of lactate levels (6 to 3.2 mmol/l) over the next hours

12. Case report
Next morning:
•Echo: Worsening of contractility (despite inotropes)
•Decreasing urine output
•Rising lactate levels

13. Case report
a-v ECMO in the awake patient

14. Case report
ECMO weaning:
•Day 7: Administration of levosimendan
•Day 8: Reduction of ECMO blood flow (500 ml every 4h)
•Day 9: ECMO removal under dobutamine (200 mcg/min)
•Day 10: Reduction and stop dobutamine
Start ACE inhibitor
Normalisation of cardiac function

15. The AHF syndromes
Cardiogenic shock Pulmonary edema Congestive HF
Typical scenario Fulminant
myocarditis
Hypertensive
emergency in
diastolic HF
Malcompliance in
dilated
cardiomyopathy
Signs and symptoms Tissue hypoperfusion
(lactate >2 mmol/l);
Organ dysfunction
(ecephalopathy, renal
failure, liver
dysfunction)
Dyspnoea at rest;
Bilateral rales;
Hypoxemia (SaO2
<90%)
Dyspnoea at exercise;
Weight gain, ascites,
peripheral oedema
Diagnostic test ABGA (lactate,
metabolic acidosis)
Chest x-ray NT-proBNP

16. The AHF syndromes
Zannad F. Eur J Heart Fail 2006; 8: 697-705

17. How can we improve the prognosis
□ Appropriate fluid management
□ Reasonable use of inotropes and vasopressors
□ Novel concepts

18. Cardiogenic shock Pulmonary edema Congestive HF
Volemia Intravascular
hypovolemia (low
fluid intake, fluid
losses, diuretics)
Fluid redistribution Hypervolemia
(weight gain, ascites,
peripheral oedema)
Diuretic use Contraindicated Careful (furosemide
10 mg i.v. push)
Indicated
(furosemide infusion
1-10mg/h)
Fluids Fluid challenge
recommended
If shock develops Fluid restriction
Fluid balance target Urine output 0.3-0.5
ml/kg/h
Neutral fluid balance Negative fluid
balance
Fluid management

19. Intravascular hypovolemia due to
•Excessive use of i.v. diuretics
•Increased perspiratio insensibilis
•Reduced fluid intake
Frank Starling mechanism

20. 250 ml of Ringer lactate over 15 minutes i.v.
Fluid challenge

21. Vasoactive drugs
Cardiogenic shock Pulmonary edema Decompensated CHF
Blood pressure Low (or normal) High Normal
Inotropes Dobutamine,
adrenaline,
milrinone,
levosimendan
Not indicated Not indicated
Vasoactive drugs Vasopressors
(noradrenaline)
Vasodilators
(nitroprusside)
Vasodilators
(nitrates)
Hemodynamic
targets
MAP 55-75 mmHg,
Lactate < 2.2 mmol/l
SvO2 > 60%
CI >2.2 l/min/m2
MAP 65-85 mmHg Individual targets

22. SOAP II study:
Subgroup of patients with cardiogenic shock (n=280)
De Backer D. N Engl J Med 2010; 362: 779-89
Log rank p=0.03
Vasopressors
Noradrenaline
Dopamine

23. Arrigo M. Intensive Care Med 2015: 41: 912-5
Inotropes

24. Stimulation of 1-receptors: adrenaline,
dobutamine
Rudiger A. Crit Care Med 2007; 35: 1599-1608

25. Dobutamine
1 and 2 receptor agonist:
Positive inotropic and chronotropic effects, vasodilation
CI , HR , systemic and pulmonary BP  or = or 
• Half-life 2 minutes
• Dose 2-5 g/kg/min (no bolus required)
• High doses needed if patient is treated with beta-blockers
• Tolerance after 48h

26. Phosphodiesterase-inhibitors:
milrinone
Rudiger A. Crit Care Med 2007; 35: 1599-1608

27. Milrinone
Phosphodiasterase III-inhibitor
Postive inotropic and chronotropic effects, vasodilation
CI , HR , BP 
• Half-life 2 hours
• Dose 5-20 g/min (bolus required)

28. Levy B. Crit Care Med 2011: 39: 450-5
Dobutamine + Noradrenaline
Adrenaline

29. Mebazaa A. Intensive Care Med 2011; 37:290-301

30. Smith G. Br Med J 2003; 327: 1459-61

31. What is the problem with inotropes?
• Catecholamines have dangerous side effects !
• Catecholamines are overused !

32. Rudiger A. Crit Care Med 2010; 38: S608-12
Adverse effects

33. Arrigo M. Intensive Care Med 2015: 41: 912-5
Adverse effects

34. Singer M. PLoS Med 2005; 2: e167

35. Follath F. Intensive Care Med 2011; 37: 619-26
12%
39%
Overuse

36. How can the use of inotropes be reduced ?
• Only use inotropes in patients with cardiogenic shock (low
contractility, low cardiac output, signs of organ dysfunctions)
• Chose reasonable targets (MAP, SvO2, lactate)
• Reduce the dose of inotropes to a minimum
• Consider alternatives

37. Levosimendan
Calcium sensitizer: positive inotropic and lusitropic effects,
Activation of K+
(ATP) channels: vasodilation, preconditioning
CI , HR = or , systemic and pulmonary BP
Dose:
Infusion 0.05-0.2 mcg/kg/min for 24h
Papp Z. Int J Cardiol 2012; 159: 82-7

38. Arrigo M. Intensive Care Med 2015: 41: 912-5
Levosimendan

39. Levosimendan
How to prevent adverse effects of levosimendan:
• Omit bolus
• Expect hypotension after 2-3 hours
• Optimize intravascular filling
• Withhold diuretics and vasodilators
• Treat hypotension with fluids and noradrenaline
• Correct electrolytes to reduce the risk of arrhythmia

40. Mebazaa A. Intensive Care Med 2011; 37:290-301
Levosimendan

41. Greco T. Br J Anesth 2015; 114: 746-56

42. Sommer W. Art Org 2015 [epub ahead of print]

43. From: twitter.com/winchester_jj/status/444916588387381248
Summary

44. Summary
How to improve the prognosis of cardiogenic shock?
• Treat underlying heart disease
• Correct intravascular fluid deficit
• Only use inotropes in cardiogenic shock
• Anticipate adverse drug effects

45. Summary
How to improve the prognosis of cardiogenic shock?
• Chose reasonable (hemodynamic) targets
• Reduce the dose of inotropes to a minimum
• Consider awake ECMO as bridge to
– decision
– bridge (for transplantation)
– recovery

46. Thank you!
alain.rudiger@usz.ch