THERAPY OF CARDIOGENIC-SHOCK

Cardiogenic shock is a syndrome of different etiologies resulting in t he inability of the heart to provide adequate O-2 delivery to peripher al organs and tissues with or without signs of severe pulmonary conges tion or pulmonary edema. Clarification of the underlying etiologies is essential for prognosis and therapy. Depending on the various etiolog ies, the therapeutic procedure may be totally different. Furthermore, it is decisive to differentiate between an acute shock (e.g., acute my ocardial infarction) and the development of a cardiogenic shock state on the basis of preexisting chronic congestive heart failure (e.g., co ngestive cardiomyopathy). Whenever possible the underlying disease sho uld be treated causally (e.g., PTCA or thrombolytic therapy in AM, lys is in acute pulmonary embolism) in addition to symptomatic pharmacolog ic treatment with vasodilators and/or inodilators. In myogenic cardiog enic shock, the treatment with inotropic drugs (with and without vasod ilatory potency) and, if necessary, in combination with additional vas odilators may be life-saving. At present, there is no alternative to c atecholamines in the acute state with apparent hemodynamic instability . Catecholamines still represent the initial first line treatment. A S wan-Ganz catheter is mandatory in such situations. In view of the rapi d beta(1)-receptor down-regulation induced by endogenous catecholamine s, long-term administration of exogenous catecholamines (adrenalin, do pamine, dobutamine), seems essentially problematic, since these compou nds intensify and accelerate this process. New beta(1)-receptor-indepe ndent alternatives with considerable inotropic properties are beta(2)- agonists (dopexamine), PDE-III-inhibitors (amrinone, milrinone, enoxim one), and H-2-receptor agonists (impromidine, arpromidine), as well as Ca++ sensitizers (Pimobendane). Initial results with these compounds are promissing to decrease the present mortality rate of 85-95 %. The availability of these new pharmacologic interventions and their applic ation with mechanical left-heart assist devices (e.g. TABP, Hemopump, percutaneous heart lung machine, Novacor) may profoundly increase ther apeutic efficacy. Convicing results, however, have not yet been report ed in the world literature.