Kardiogener Schock – aktueller Stand der Pathophysiologie, Therapie und Prognose

Der kardiogene Schock (CS) ist keine singuläre Erkrankung, sondern ein komplexes Syndrom. Nur für wenige Therapien ist bewiesen, dass sie die Prognose verbessern: Dies sind seit über 20 Jahren die frühzeitige Revaskularisation bei infarktbedingtem CS und seit diesem Jahr der Einsatz perkutaner linksventrikulärer Unterstützungssysteme bei ausgewählten Patienten [1] [2] [3]. Somit bleiben viele Fragen zur Therapie offen, wie dieser Beitrag zeigt.

Abstract

Cardiogenic shock is not a singular disease but rather a complex syndrome – characterized by systemic hypoperfusion, elevated intracardiac pressures, and insufficient cardiac output due to various possible underlying causes, leading to an acute, life-threatening, and critical condition.
Significant advancements have been made in recent years in understanding the epidemiology, clinical course, phenotyping, hemodynamics, and the standardized classification of disease severity. However, progress in therapeutic interventions aimed at improving prognosis has been comparatively limited, with only a few therapies demonstrating significant evidence in randomized controlled trials. Among these, early revascularization in infarct-related cardiogenic shock (Acute Myocardial Infarction with Cardiogenic Shock – AMICS) has remained a key therapy for more than 20 years, and more recently, the use of percutaneous left ventricular assist devices in selected patients.
Many questions remain unanswered, including the optimal pharmacotherapeutic regimen, the role of other mechanical support systems, the management of secondary organ dysfunction, and the best approach to supportive care.

Kernaussagen

• Der kardiogene Schock (CS) ist ein komplexes Syndrom mit hoher Mortalität und Morbidität. Die Assoziation mit einem akuten Myokardinfarkt (AMI) ist häufig, und diese Schockform ist in Studien inzwischen gut untersucht. Die Inzidenz dieses AMICS geht aber zurück.

• Risikomodifikatoren des CS sind die verschiedenen möglichen Phänotypen, klinische Ereignisse wie Reanimation, extrakardiale Organ-Dysfunktionen und Inflammation.

• Grundpfeiler der initialen Therapie sind die frühzeitige Revaskularisation bei AMICS und eine differenzierte, an hämodynamische Bedürfnisse angepasste medikamentöse Therapie. Diese umfasst eine Volumengabe, Norepinephrin und positive Inotropie durch z.B. Dobutamin, Milrinon oder Levosimendan.

• Eine maschinelle Therapie mittels Impella ist bei selektierten Patienten mit AMICS mit einer verbesserten Prognose verbunden. Eine standardisierte VA-ECMO-Therapie bei AMICS ist nicht durch eine solche Prognosenverbesserung gekennzeichnet. Die Daten zur Kombinationstherapie der Systeme und zur Anwendung bei anderen Formen des CS sind noch unzureichend.

• Die Prognose des CS bleibt mit einer deutlichen kurzfristigen Mortalität verbunden.

Schlüsselwörter

kardiogener Schock - akute Herzinsuffizienz - Intensivmedizin - Kardiologie

Keywords

cardiogenic shock - acute heart failure - critical care - cardiology

Publication History

Article published online:
14 March 2025

• Literatur

• 1 Hochman JS, Sleeper LA, Webb JG. et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med 1999; 341: 625-634
• 2 Thiele H, Akin I, Sandri M. et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med 2017; 377: 2419-2432
• 3 Møller JE, Engstrøm T, Jensen LO. et al. Microaxial flow pump or standard care in infarct-related cardiogenic shock. N Engl J Med 2024; 390: 1382-1393
• 4 Thiele H, Zeymer U, Neumann FJ. et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367: 1287-1296
• 5 Thiele H, Zeymer U, Akin I. et al. Extracorporeal life support in infarct-related cardiogenic shock. N Engl J Med 2023; 389: 1286-1297
• 6 Ostadal P, Rokyta R, Karasek J. et al. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial. Circulation 2023; 147: 454-464
• 7 Mebazaa A, Nieminen MS, Packer M. et al. Levosimendan vs dobutamine for patients with acute decompensated heart failure: the SURVIVE randomized trial. JAMA 2007; 297: 1883-1891
• 8 Waksman R, Pahuja M, van Diepen S. et al. Standardized definitions for cardiogenic shock research and mechanical circulatory support devices: scientific expert panel from the shock academic research consortium (SHARC). Circulation 2023; 148: 1113-1126
• 9 Naidu SS, Baran DA, Jentzer JC. et al. SCAI SHOCK Stage Classification Expert Consensus Update: A Review and Incorporation of Validation Studies: This statement was endorsed by the American College of Cardiology (ACC), American College of Emergency Physicians (ACEP), American Heart Association (AHA), European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC), International Society for Heart and Lung Transplantation (ISHLT), Society of Critical Care Medicine (SCCM), and Society of Thoracic Surgeons (STS) in December 2021. J Am Coll Cardiol 2022; 79: 933-946
• 10 Morici N, Frea S, Bertaina M. et al. SCAI stage reclassification at 24 h predicts outcome of cardiogenic shock: Insights from the Altshock-2 registry. Cathet Cardiovasc Intervent 2023; 101: 22-32
• 11 Berg DD, Bohula EA, van Diepen S. et al. Epidemiology of shock in contemporary cardiac intensive care units. Circ Cardiovasc Qual Outcomes 2019; 12
• 12 Chioncel O, Parissis J, Mebazaa A. et al. Epidemiology, pathophysiology and contemporary management of cardiogenic shock – a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020; 22: 1315-1341
• 13 Wenzl FA, Bruno F, Kraler S. et al. Dipeptidyl peptidase 3 plasma levels predict cardiogenic shock and mortality in acute coronary syndromes. Eur Heart J 2023; 44: 3859-3871
• 14 Schmidt M, Burrell A, Roberts L. et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J 2015; 36: 2246-2256
• 15 McDonagh TA, Metra M, Adamo M. et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2021; 42: 3599-3726
• 16 Mathew R, Di Santo P, Jung RG. et al. Milrinone as compared with dobutamine in the treatment of cardiogenic shock. N Engl J Med 2021; 385: 516-525
• 17 Fernando SM, Mathew R, Sadeghirad B. et al. Inotrope, vasopressors, and mechanical circulatory support for treatment of cardiogenic shock complicating myocardial infarction: a systematic review and network meta-analysis. Can J Anaesth 2022; 69: 1537-1553
• 18 Zeymer U, Freund A, Hochadel M. et al. Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials. Lancet 2023; 402: 1338-1346
• 19 Suverein MM, Delnoij TSR, Lorusso R. et al. Early Extracorporeal CPR for refractory out-of-hospital cardiac arrest. N Engl J Med 2023; 388: 299-309
• 20 Beer BN, Besch L, Weimann J. et al. Incidence of hypoxic hepatitis in patients with cardiogenic shock and association with mortality. Eur Hear J Acute Cardiovasc Care 2023; 12: 663-670
• 21 Fernando SM, Qureshi D, Talarico R. et al. Mental health sequel in survivors of cardiogenic shock complicating myocardial infarction. A population-based cohort study. Intensive Care Med 2024; 50: 901-912