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RECONSIDERING VASOPRESSORS FOR CARDIOGENIC SHOCK Everything should be made as simple as possible, but not simpler

Pierre Squara, Steven Hollenberg, Didier Payen
Chest 2019 March 29
30935893
Recent scientific statements and publications have recommended the use of vasoconstrictors as the first line pharmacological choice for most cases of cardiogenic shock (CS), without abundance of strong clinical evidence. One challenge of guidelines is that the way recommendations are stated can potentially lead to oversimplification of complex situations. Except for acute coronary syndrome with CS, in which maintenance of coronary perfusion pressure seems logical prior to revascularization, physiologic consequences of increasing afterload by use of vasoconstrictors should be analyzed. Changing the CS conceptual frame, emphasizing inflammation and other vasodilating consequences of prolonged CS, mixes causes and consequences. Moreover, the considerable inter-patient differences regarding the initial cause of CS and subsequent consequences on both macro- and microcirculation, argues for a dynamic, step-by-step, personalized therapeutic strategy. In CS, vasoconstrictors should be used only after a reasoning process, a review of other possible options, and then should be titrated to reach a reasonable pressure target, while checking cardiac output and organ perfusion.

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