心因性休克 (cardiogenic shock, CS) 是一種低心輸出狀態，主要是由於心臟功能障礙導致系統性低灌流合併組織缺氧。急性心肌梗塞 (acute myocardial infarction, AMI) 是CS 最常見之病因，然而CS 是AMI 住院病人死亡的最主要原因，三十天的死亡率接近40%，一年的死亡率將近50%。臨床試驗對於CS 的定義是以臨床和血液動力學準則為依據，包含持續低血壓、終端器官灌注不良之證據和低心臟指數。執行立即性血管重建，處理與梗塞相關的冠狀動脈仍然是主要的治療型態，也是唯一具明顯減少急性心肌梗塞併發心因性休克 (AMI-CS) 死亡率的治療方式。約有90% AMICS病人需給予血管活性劑 (vasoactive medications) 包含升壓劑 (vasopressors) 和強心劑 (inotropes) 處理其低血壓和（或）低灌流狀況。各種研究顯示norepinephrine具較低心律不整發生風險，比dopamine 或epinephrine 更安全。臨床治療指引推薦norepinephrine 是CS 病人維持灌流壓的首選升壓劑 (IIb/B)。機械式循環輔助(mechanical circulatory support, MCS) 被使用於對升壓劑和強心劑難治療的AMICS病人( IIb/C)。經由文獻回顧與分析，基於目前實證和臨床治療指引，本文將討論AMI-CS 病人之流行病學與預後、定義與分類、病理生理學、處理與治療。

 

Cardiogenic shock (CS) is a condition characterized by inadequate cardiac output, leading to systemic hypoperfusion and tissue hypoxia caused by cardiac dysfunction. The primary etiology of CS is acute myocardial infarction (AMI). CS is the leading cause of mortality in patients admitted with AMI, with a 30-day mortality rate of nearly 40% and a one-year mortality rate of approximately 50%. Clinical trials have defined CS based on clinical and hemodynamic criteria, which include sustained hypotension, signs of end-organ malperfusion, and a low cardiac index. Emergency revascularization of the infarct-related coronary artery remains the mainstay of treatment and is the only therapy that has significantly reduced mortality for CS following AMI (AMI-CS). Vasoactive medications (vasopressors and inotropes) are prescribed to nearly 90% of patients with AMI-CS to manage hypotension and/or hypoperfusion. Various studies showed that norepinephrine is safer than dopamine or epinephrine with a lower risk of atrial arrhythmias. Norepinephrine should be the first-line vasopressor recommended by guidelines to sustain perfusion pressure in CS patients (IIb/B). Mechanical circulatory support are used for treating patients with AMI-CS refractory to vasopressors/inotropes (IIb/C). Through the literature review and analysis, this article will discuss the epidemiology and prognosis, definition and classification, pathophysiology, management and treatment of patients with AMI-CS based on current evidence and clinical practice guidelines.

 

 

Submitted for publication: 2022.11.16; Accepted for publication: 2023.2.2