Cardiogenic shock: predictors of outcome based on right and left ventricular size and function at presentation

In Brief Objective To determine the characteristics and prognostic importance of right ventricular (RV) dilatation and dysfunction in patients with cardiogenic shock secondary to left ventricular (LV) dysfunction enrolled in the Should we emergently revascularize occluded coronaries for cardiogenic shock (SHOCK) trial. Methods LV and RV size and function were quantified by echocardiography in 99 patients with cardiogenic shock secondary to predominant LV dysfunction. Results For all patients, RV dysfunction was not associated with a poor 1-year survival. When the 59 patients with RV dysfunction were stratified into two morphologic groups based upon LV-to-RV end-diastolic area ratio (LV/RV) < or ≥2, the presence of disproportionate RV enlargement (LV/RV <2) was associated with inferior myocardial infarction (80%) and right coronary artery culprit disease (79%). In contrast, the index myocardial infarction in patients with predominant LV enlargement (LV/RV ≥2) was anterior (69%) and associated with left anterior descending artery disease (64%). Patients with LV/RV <2 had significantly higher right atrial pressures (20.1±5.2 compared with 14.5±8.9 mmHg, P=0.001) and lower RV fractional area change (20.4±8.7 compared with 33.5±11.0%, P=0.0001), heart rate (87±21 compared with 106±23 beats/min, P=0.006) and cardiac index (1.5±0.5 compared with 2.0 ±0.9 l/min per m2, P=0.007) than patients with LV/RV ≥2. Despite the hemodynamic profile and severity of RV dysfunction in the LV/RV <2 group, 12-month survival was significantly greater in these patients (70% LV/RV <2 compared with 34% LV/RV ≥2, P=0.027). Conclusions In patients with cardiogenic shock secondary to predominant LV failure, the presence of RV dilatation and dysfunction identifies a subgroup of patients with predominant inferior myocardial infarction and an improved long-term prognosis. To determine the prognostic importance of right ventricular dilatation and dysfunction in patients with cardiogenic shock, left and right ventricular size and function were studied by echocardiography in 99 patients enrolled in the SHOCK trial. The presence of disproportionate right ventricular enlargement compared to the left ventricle was associated with inferior MI (80%) and right coronary artery culprit disease (79%). In contrast, the index MI in patients with predominant LV enlargement was anterior (69%) and associated with left anterior descending artery disease (64%). The one-year survival was significantly greater in the patients with disproportionate RV enlargement.Thus in patients with cardiogenic shock secondary to predominant LV failure, the presence of RV dilatation and dysfunction identifies a subgroup of patients with predominant inferior MI and an improved long term prognosis.