Measurement of cardiac reserve in cardiogenic shock: implications for prognosis and management.

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Abstract
The hypothesis that the prognosis of cardiogenic shock patients is primarily dependent on cardiac pumping reserve was tested in a prospective study of 28 consecutive patients clinically diagnosed to be in cardiogenic shock and treated medically. Haemodynamic function was assessed by thermodilution Swan-Ganz catheters and arterial cannulas. The cardiac pumping reserve was evaluated by the response of the failing heart to graded incremental dobutamine infusion (2.5 to 40 micrograms/kg/min) after optimalising the left ventricular preload. Eleven of the patients survived for more than the one year of follow up and the rest died. Haemodynamic evaluation during the basal resting state was only able to identify unambiguously non-survivors whose cardiac function was most severely compromised. Survivors and non-survivors with higher values were indistinguishable by basal haemodynamic criteria. The response to dobutamine stimulation clearly separated the cardiac pump function of survivors and those who died. All patients with peak cardiac power output of less than 1.0 W or peak left ventricular stroke work index of less than 0.25 J/m2 died whereas all those with higher values lived for more than a year. Thus this study showed that haemodynamic evaluation of cardiac reserve can provide objective criteria for predicting outcome in individual patients with cardiogenic shock. The availability of such a prognostic indicator will be invaluable in formulating management plans for these patients.