Shock cardiogeno
Table of Contents
Definizione
Lo shock cardiogeno è una condizione clinica caratterizzata da una riduzione della portata cardiaca ed ipossia tissutale in presenza di un adeguato volume ematico intravascolare dovuta a un deficit del miocardio o dell’apparato valvolare cardiaco. Lo shock cardiogeno si presenta con ipotensione (pressione arteriosa sistolica < 90 mmHg per almeno 30 minuti), riduzione dell’indice cardiaco ed elevata pressione capillare.La causa più frequente è l’infarto del miocardio. altre cause sono:
- Rottura del miocardio
- Aritmie
- Insufficienza valvolare
- Stenosi valvolare
- Cadiomiopatie dilatative
- In associazione ad unoshock ipovolemicoo uno shock ostruttivo extra-cardiaco
- Tamponamento pericardico
- Pericardite restrittiva
- Dissezione aortica
- Embolia polmonare massiva
- Cuore polmonare
L’infarto del miocardio è la causa più frequente di shock cardiogeno; infatti, si manifesta nel 10-15% dei pazienti ricoverati per infarto ed è la più comune causa di morte nei pazienti ricoverati in Unità di Terapia Intensiva Coronarica; quindi, lo shock cardiogeno è tipicamente l’espressione clinica di una necrosi massiva.
Manifestazioni cliniche
- Il paziente si presenta in genere dispnoico, spesso in stato confusionale o semicosciente, e può riferire dolore retrosternale (se vi è una sottostante cardiopatia ischemica).
- La cute è fredda e sudata, con ampie aree marezzate da macchie cianotiche.
- I polsi radiali sono spesso non apprezzabili e quelli carotidei e femorali sono piccoli e frequenti.
- La pressione arteriosa è bassa (<90 mmHg o addirittura non misurabile).
- La diuresi è molto scarsa o assente (oliguria o anuria) ed è presente grave acidosi metabolica.
Monitoraggio emodinamico
Ilmonitoraggio emodinamicodel paziente riveste un ruolo di notevole importanza sia nella stratificazione prognostica, sia nella terapia delloshock cardiogeno. I particolare in aggiunta al ritmo cardiaco, alla saturazione di O2, alla diuresi, la frequenza respiratoria, all’equilibrio acido-basico, nei pazienti con shock cardiogeno devono essere costantemente valutati i seguenti parametri emodinamici:
- Pressione venosa centrale: questo parametro è misurato attraverso il posizionamento di un catetere in vena cava superiore collegato a un trasduttore di pressione.
- Pressione arteriosa polmonare e pressione di incuneamento capillare polmonare: questi parametri vengono misurati mediante un apposito catetere (catetere di Swan-Ganz) posizionato attraverso un accesso venoso centrale nelle sezioni destre del cuore fino ai rami polmonari, collegato a un trasduttore di pressione.
- Pressione arteriosa: il monitoraggio invasivo della pressione arteriosa consente un’accurata valutazione della pressione arteriosa sistolica, diastolica e media; inoltre, permette la valutazione della morfologia dell’onda sfigmica; è misurata abitualmente utilizzando una cannula posizionata nell’ arteria radiale collegata a un trasduttore di pressione arteriosa.
- Portata cardiaca: questo parametro è il prodotto tra gittata sistolica e frequenza cardiaca e viene espresso in L/min.
Bisogna tenere presente che la misurazione di questi parametri è importante non sono per la diagnosi di shock cardiogeno, ma anche per valutare la risposta alla terapia nel tempo.
Diagnosi
La diagnosi deve essere tempestiva. Tramite l’utilizzo dell’ecocardioscopia bed-sideè già possibile valutare la funzione contrattile cardiaca e lo stato dell’apparato valvolare cardiaco. Può essere utile il monitoraggio invasivo della portata cardiaca con uncatetere di Swan-Ganzo con il metodo dellatermodiluizione, della pressione venosa centrale (PVC) dell’ScvO2e dell’SvO2.
Terapia
L’obiettivo ideale dellaterapia farmacologica nello shock cardiogenoè migliorare la perfusione periferica aumentando l’efficienza contrattile del miocardio e cercando allo stesso tempo di produrre (se aumentate) le resistenze periferiche. Questo scopo può essere ottenuto con l’uso combinato difarmaci inotropi e vasodilatatori. Tuttavia, in diversi casi le resistenze periferiche sono già ridotte per la prevalenza della vasodilatazione reattiva periferica, per cui spesso, soprattutto quando non si riesce a ottenere un aumento apprezzabile della contrattilità miocardica, l’obiettivo primario è, all’opposto, quello di aumentare le resistenze per sostenere la pressione a vantaggio della perfusione degli organi vitali più importanti.
Come farmaci di prima linea per migliorare la funzione di pompa cardiaca si usano i vasopressori inotropi simpaticomimetici:dobutamina, dopamina, adrenalina associati a un farmaco vasopressore come la noradrenalina.
Tra le terapie farmacologiche oggi disponibili si può utilizzare uncalcio-sensibilizzante, che aumenta la contrattilità cardiaca, come il levosimendan per via endovenosa.
In caso di shock cardiogeno refrattarie al trattamento farmacologico possono essere utilizzatidispositivi di assistenza ventricolare (VAD). Una misura di supporto temporaneo è costituita dalcontropulsatore aortico, da utilizzare solo nei pazienti con lesioni cardiache correggibili con una ragionevole possibilità di ripresa dopo la lesione cardiaca iniziale o in attesa di trapianto.
Articoli correlati:
Infarto miocardico acuto (IMA)
UN CASO DI SHOCK CARDIOGENO: INQUADRAMENTODIAGNOSTICO PRECOCE E INIZIALE TRATTAMENTO CON INOTROPI E VASOPRESSORI
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