[Cardiogenic shock complicating myocardial infarction]

[Clinical acute and emergency medicine curriculum-focus on internal medicine : Recommendations for advanced training in internal medicine in the emergency department]

In Germany, physicians qualify for emergency medicine by combining a specialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.

Pharmacological treatment of cardiogenic shock - A state of the art review

Cardiogenic shock is a clinical syndrome of impaired tissue perfusion caused by primary cardiac dysfunction and inadequate cardiac output. It represents one of the most lethal clinical conditions in intensive care medicine with mortality >40%. Management of different clinical presentations of cardiogenic shock includes guidance of cardiac preload, afterload, heart rate and contractility by differential pharmacological modulation of volume, systemic and pulmonary vascular resistance and cardiac output besides reversing the triggering cause. Data from large registries and randomized controlled trials on optimal diagnostic guidance as well as choice of pharmacological agents has accrued significantly in recent years. This state-of-the-art review summarizes the basic concepts of cardiogenic shock, the diagnostic work-up and currently available evidence and guideline recommendations on pharmacological treatment of cardiogenic shock.

[Pharmaceutical therapy of infarct-related cardiogenic shock]

Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a comparably seldom but fatal entity. The definition of cardiogenic shock - unlike e. g. septic shock - is not uniform. Immediate revascularization is central to the patient's prognosis in AMI-CS. Patients who continue to meet the criteria of shock despite revascularization should be hemodynamically phenotyped to allow guidance of personalized subsequent therapy. Antiplatelet medication is the cornerstone for maintaining myocardial (re)perfusion. In hypotension, norepinephrine should be used as the first-line vasopressor, depending on afterload and after compensation for possible hypovolemia. Dobutamine is recommended to increase inotropy, possibly augmented or substituted by calcium sensitizers such as levosimendan. PDE-III (phosphodiesterase enzyme type III)-inhibitors should be used with restraint in myocardial infarction. Dopamine is no longer recommended in Europe. A sasodilator may be an option in highly selected patients with AMI-CS. This review will provide a detailed updated overview on pharmacological treatment modalities and indications in individual patients.