What is Cardiogenic Shock?

24 November 2021

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Cardiogenic Shock Symptoms: Causes, Effects, and Treatmentsdd

Cardiogenic Shock Explained

First we need to ask, what is Cardiogenic Shock (CS)? CS is a life-threatening condition whereby the heart can’t pump enough blood to meet the body’s needs. While a severe heart attack most often causes it, not everyone who has a heart attack experiences cardiogenic shock. While a serious heart attack usually damages the left ventricle (the main pumping chamber), it can sometimes damage the right ventricle, which pumps blood to the lungs.

Causes and Complications of Cardiogenic Shock

Myocarditis: inflammation of the heart muscle
Endocarditis: infection-induced inflammation of the inner lining of the heart
Arrhythmias: irregular heartbeat (abnormal heart) where either the lower chambers fibrillate (ventricular fibrillation) or where the ventricles beat too fast (ventricular tachycardia)
Pericardial tamponade: pressure on the heart due to excess fluid present around the heart
Pulmonary embolism: blood clot developed in a blood vessel; leads to blockage of blood flow
Rupture of the heart or damage to the valves
Critical illness: the heart is not able to contract as hard as it should after resuscitation from cardiac arrest or with critical illness following trauma or severe infections

Understanding Heart Disease Symptoms

Symptoms may present fast and include sudden shortness of breath, fainting, dizziness, confusion, anxiety, sweating, chills, rapid and weak heartbeat or heart rhythm, fatigue, or low or absent urinary output. Patients with cardiogenic shock may also enter into a coma if the shock is not treated quickly enough. Furthermore, because cardiogenic shock usually results from a heart attack, patients will usually experience heart attack symptoms – chest pain/pressure, shoulder & arm pain, sweating, nausea, and vomiting.

How a Medical Doctor Can Diagnose CS

A doctor can confirm a Cardiogenic Shock diagnosis by supplementing patient symptoms with testing and vital signs. Testing can include performing an ECG, chest x-ray, blood tests, echocardiogram, or cardiac catheterization. Patients with any type of shock present with low blood pressure end end-organ hypoperfusion (e.g., low urine output). Cardiogenic Shock patients specifically have a low cardiac output, elevated ventricle filling pressures, and decreased venous oxygen saturation.

Managing Heart Failure Disease

Unfortunately, Cardiogenic Shock is a complex disease frequently associated with multisystem organ failure. Few evidence-based interventions can definitively improve patient outcomes. Emergency treatment includes oxygen administration and mechanical ventilation in more severe cases.

Medications Administered to Increase the Heart’s Ability to Pump Blood & Reduce Blood Clot Risk After Cardiogenic Shock.

Vasopressors: Used to treat low blood pressure (e.g., dopamine, epinephrine, norepinephrine)
Inotropic agents: Used to improve heart pumping function (e.g., dobutamine, dopamine, milrinone)
Blood-thinning medications:
- Aspirin: Used sparingly to reduce blood clotting and keep blood moving through arteries
- Antiplatelets: Used to prevent blood clotting (e.g., Plavix)
- Others such as heparin

Beyond medication and immediate treatment, procedures to restore regular blood flow can be performed on patients experiencing Cardiogenic Shock Symptoms. Inside the body, angioplasty and stenting help open blocked arteries and facilitate blood flow to the heart. A balloon pump can be used to assist the heart in pumping blood to the body. Alternatively, in very sick patients, extracorporeal membrane oxygenation (ECMO) allows efficient blood pumping outside of the body through a heart-lung machine.

Doctors can perform surgery on Cardiogenic Shock patients as a last resort, such as coronary artery bypass surgery or a heart transplant.

Epidemiology

Cardiogenic Shock is the leading cause of death after myocardial infarction (a heart attack). Higher incidences of CS occur in women, Asian/Pacific Islanders, and patients older than 75. CS incidence has increased due to improved diagnosis and better global access to care. 6 to 12 month mortality is approximately 50% but can be as high as 70-90% in the absence of aggressive, highly experienced technical care.

Classifying Symptom Severity for Enhanced Treatment Strategies

As there is a broad spectrum of clinical severity among patients presenting with CS, a classification system developed in 2019 stratifies CS into five categories: A (At Risk), B (Beginning), C (Classic), D (Deteriorating), and E (Extremis). CS is difficult to study because patients can deteriorate rapidly, informed consent is hard to obtain from the patient, and a variety of heterogeneous disease states can present as cardiogenic shock. Improved clinical characterization and risk assessment of CS patients may lead to more effective clinical treatment and outcomes in the future.

CVRTI’s Center for Study in Cardiology and Heart Disease

Years of basic and clinical research have positioned investigators from the Nora Eccles Harrison Cardiovascular Research and Training Institute as world leaders in understanding heart biology. In addition, a clear understanding of the mechanisms of injury has led to several therapeutic advancements. The CVRTI’s excellence has materialized in the Utah Cardiac Recovery Program or UCARS . This is a registry that focuses on better understanding CS to improve patient outcomes ultimately. Investigators have also developed a team approach to care for patients with severe CS. They demonstrated that patients managed by a multi-disciplinary team (heart failure cardiologist, heart failure cardiothoracic surgeon, interventional cardiologist, and a Cardiovascular Intensive Care Unit physician) do better. Other groups at the CVRTI focus on developing novel drugs to protect and rescue injured hearts in both acute and chronic conditions. Investigators from the CVRTI have discovered two proteins (GJA1-20k and cBIN1) that are key players in normal myocardial function. Those molecules could be used to treat CS . Our investigators are testing whether administering those proteins can protect the heart after blockage of the main arteries in the heart or following major traumatic injuries. If successful, those groups could champion significant advances that will improve CS patients’ survival.

What is Electrophysiology?

26 October 2021

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What is Electrophysiology and Its Relation to Heart Health?

Blue Figure with Arms Outstretched and Bright Red Heart - CVRTI Electrophysiology Graphic

We all know the feeling of our heart racing or fluttering as we get excited, nervous, or stressed. But what is going on in the heart to get a heart rhythm? The heart contracts and expands to pump blood through the body using an electrical stimulus that starts in the heart’s sinoatrial node. That electrical stimulus travels through the four chambers of the heart to give the heart the ability to pump blood. Electrophysiology is the study of the electrical patterns in the heart. Electrophysiologists are doctors who specialize in the heart’s electrical patterns and most commonly treat patients with heart arrhythmias.

An Overview of Electrophysiological Research, Heart Arrhythmias, and Atrial Fibrillation

Arrhythmias are any problems with the heartbeat. Arrhythmias can feel like the heart fluttered, skipped a beat, suddenly started racing, or is beating very slow. These sensations can normally occur when experiencing different emotions. But most commonly for arrhythmia patients, this occurs because of a disruption in the heart’s electrical pathway.

When the electrical stimulus in the heart does not follow the correct electrical pathway through the heart, the heart contracts and expands either too rapidly or slowly, causing blood to flow improperly or back into the heart. The disruption in the electrical stimulus’s pathway is the cause of the arrhythmia. What can happen over time with repeated arrhythmias is that the heart cannot pump as effectively, resulting in less blood flow throughout the body. Electrophysiologists are concerned with arrhythmias when they happen unexpectedly and frequently. Not all arrhythmias are a concern, and some can be considered harmless. The earlier the diagnosis of arrhythmia, the better the outcomes for the patient. Arrhythmias can damage or weaken the heart and the heart’s ability to pump blood. Treatment options for arrhythmias can help control the occurrence of the arrhythmia or prevent damage to the heart.

Electrophysiology and Atrial Fibrillation

Specifically, electrophysiologists are concerned with patients who experience atrial fibrillation. Atrial fibrillation (also known as AFib) is an arrhythmia where the chambers of the heart begin to rapidly beat and look like they are quivering. Blood can get unexpectedly pushed into the atria of the heart. The trapped blood can lead to blood clots or strokes. Atrial fibrillation is a severe worldwide disorder and is expected to affect around 40 million people. Early diagnosis of is vital to ensure successful outcomes.

What is an Electrophysiology Study of the Heart?

Electrophysiologists conduct an electrophysiology study on patients to diagnose arrhythmias and atrial fibrillation. As part of the diagnosis, electrophysiologists will pinpoint where the electrical pattern is getting disrupted in the heart. From the study results, the electrophysiologist will be able to determine if medications, ablation therapy, or routine monitoring are needed to treat the patient. Even with electrophysiology studies, arrhythmias can be difficult to diagnose. Patients undergoing an electrophysiology study are often not experiencing constant arrhythmias. However, early diagnosis and treatment of arrhythmias are essential to ensure no further damage to the heart.

CVRTI’s Research in Electrophysiology & Abnormal Heart Rhythms

At the Nora Eccles Harrison Cardiovascular Research and Training Institute (CVRTI), researchers are committed to learning how to better understand the heart’s electrical patterns. There has been a long-standing focus on cardiac rhythm and its disorders since the foundation of the institute. The CVRTI is exploring new technologies to better diagnose and help patients who suffer from arrhythmias and other heart rhythm disorders. CVRTI researchers have changed the landscape of electrophysiology by understanding how cardiac bioelectricity creates the electrocardiographic signal, both in health and disease and deciphering how ion channels and transporters create the heartbeat and become altered. CVRTI researchers are dedicated to the study of the genomic basis of inherited arrhythmia syndromes and studying how risk factors, such as obesity , affect arrhythmia incidence and mortality. Finally, the structural basis of atrial fibrillation , the most common rhythm disorders, is being elucidated by pioneering imaging studies . In all, the CVRTI continues to lead the way in electrophysiological reasearch and understanding how rhythm disorders develop and creating tools to study and treat these in patients.

CVRTI researchers are also learning the ion channels that generate electrical signals in the heart have other roles as well. Ion channels can regulate mitochondria , which is the power center of each muscle cell, as well as cell organization . Also, the proteins that organize ion channels can be used to rescue failing heart muscle as well as help clinicians quantify the extent of heart muscle failure . The more we learn about ion channel, the better our understanding that these basic building blocks are not just important for the heart’s electrical system, but for heart function as well.

What is Cardiac Arrhythmia?

16 September 2021

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What is Cardiac Arrhythmia?

Heart with Blue EKG Lines Behind - CVRTI Cardiac Arrhythmia Blog Image

The heart’s primary function is to pump blood throughout the body. This is done by an electrical connection that originates from the sinoatrial node (SA node). The electrical impulse begins at the SA node travels throughout the heart. The electrical impulse travels along a pathway through the heart to create the heart’s movement. The movement or pumping is what allows the blood to flow in and out of the heart in the appropriate direction. A disturbance in that electrical pathway can impact the heart’s ability to pump blood or heart rate. Changes to the heart’s electrical impulses result in irregular heartbeat / heart rhythm or cardiac arrhythmias.

Types of Cardiac Arrhythmia

Cardiac arrhythmias are any type of irregularity in heart rhythm which results in a change in heart rate. Arrhythmias are classified by the impact they have on heart rate and where the heart they originate:

Tachycardia

A cardiac arrhythmia that creates a faster than usual heart rate.

Bradycardia

Arrhythmias create slower than resting heart rates.

Are Arrhythmias a Symptom of Heart Failure?

Arrhythmias can also impact heart rate as a flutter in heart rate or premature heartbeat. Patients describe these arrhythmias like the heart skipped a beat. Tachycardia and bradycardia arrhythmias are not necessarily a sign of heart disease or heart failure because daily activity such as exercise, stress, meditation, and sleep can cause heart rates to go above or below resting.

Physician’s Evaluation of Arrhythmias

When physicians suspect a patient is having abnormal cardiac arrhythmias, they will evaluate first whether those are tachycardia or bradycardia arrhythmias. Once that is established, then physicians will evaluate where in the heart the arrhythmia is originating. The heart is split into four chambers, with two ventricles and two atria. Tachycardia arrhythmias can originate in the ventricles or the atria. Bradycardia arrhythmias typically occur at the nodes of the heart.

Common Symptoms Patients Experience

Fast heart rates are not always a sign of concern because it is normal to feel like your heart is beating rapidly during intense exercise or to feel your heart rate go down while preparing for bed. Patients who may have more arrhythmias might feel fluttering in their chest, chest pain, or unexplained shortness of breath. Outside of chest concerns, arrhythmia patients may have heightened anxiety, unexplained fatigue, fainting or feelings of fainting, lightheadedness, or unexplained sweating.

During regular routine examinations, physicians may diagnose a heart arrhythmia without the patient feeling any physical symptoms. Because arrhythmias can happen at any time, physicians may ask patients to wear a heart monitor like a Holter monitor for a few days. Some physicians may order tests like an electrocardiogram, tilt-table test, cardiac MRI to evaluate the patient’s heart health.

When Patients Should Seek Treatment

Some cardiac arrhythmias may resolve themselves on their own or may pass quickly. However, patients at risk for arrhythmia or who are experiencing arrhythmias should seek medical attention immediately. So arrhythmias, like ventricular fibrillation arrhythmia, can be deadly. In ventricular fibrillation arrhythmia, the heart will quiver making it ineffective in pumping blood, resulting in blood not getting distributed throughout the body, and vital organs will get damaged quickly without blood. Complications from arrhythmias can include cardiac arrest, stroke, or heart failure.

Common Causes of Arrhythmia

Anything that causes a disruption in the heart’s electrical pathway can result in cardiac arrhythmia. Research indicates that patients with substance abuse disorders, high caffeine usage, alcohol abuse, heart-related conditions (heart disease, heart attack, high blood pressure, electrolyte imbalance), diabetes, history of smoking, obesity, or high stress are at risk for cardiac arrhythmias. Patients at risk for arrhythmia should follow recommendations for good heart health.

Cardiac Arrhythmia Prevention

Any activity that is designed to maintain heart health is an excellent activity to prevent cardiac arrhythmias. Patients should have a diet with healthy fats and lean protein. Cardiac arrhythmia is often not seen in physically fit adults with normal heart function but can be present in structurally normal hearts. To prevent arrhythmia, patients should limit substances such as cigarettes, alcohol, caffeine, and drugs. Stress is a significant risk factor for cardiac arrhythmias, so stress and anger management is critical lifestyle to prevent arrhythmias.

Cardiovascular Research and Training Institute

Researchers at the Nora Eccles Harrison Cardiovascular Research and Training Institute (CVRTI) are studying what can impact the heart’s electrical patterns and how to best diagnose, maintain, and treat cardiac arrhythmias. The CVRTI is committed to better understanding how to maintain a healthy heart and improve heart health outcomes. Investigators are studying the mechanisms underlying atrial fibrillation and ablation techniques with the goal of improving ablation outcomes . They are also studying techniques to terminate left threatening arrhythmias without the need for shocking the heart. The genetic basis for some of these arrhythmias is also being investigated. Research at CVRTI will change the standard of care & treatment for cardiac arrhythmia patients.

Contact CVRTI for heart matters and to learn more about ongoing research for cardiac arrhythmia.

What is Sudden Cardiac Death?

26 August 2021

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Sudden Cardiac Death Causes, Symptoms and Treatments (SCD)

Blue Heart Image Representing Sudden Cardiac Death

Sudden cardiac death (SCD) is a heart arrhythmia condition when the heart abruptly stops functioning, leading to a halting of breathing and consciousness, resulting in death. SCD is one of the most significant causes of natural deaths globally. Annually, just over 300,000 US adult deaths are a result of sudden cardiac death. Roughly half of all cardiovascular disease deaths are from SCD.

SCD is caused by a sudden cardiac arrest. Sudden cardiac arrest is the result of abnormal function of the heart’s electrical system, causing the heart to suddenly beat too fast or without synchrony, impairing the heart’s ability to sufficiently pump blood. Thus, sudden altered electrical activity in the heart results in a lack of blood flow throughout the body, causing brain and other organ damage, and can result in death.

SCD is difficult to diagnose and prevent because it is hard to predict when a patient will experience arrhythmia. Further, many patients are unaware they are at risk for sudden cardiac arrest because there may not have clear symptoms of an underlying disease or cardiomyopathy.

Treatment for Sudden Cardiac Arrest

The few moments immediately after the onset of sudden cardiac arrest are the most crucial because without treatment, the risk of survival decreases. Without treatment in the first few minutes of sudden cardiac arrest, blood will not reach the brain and ultimately be followed by sudden death. During a sudden cardiac arrest, patients will need cardiopulmonary resuscitation (CPR) and defibrillation treatment to help keep blood flowing through the body. Once hospitalized, core temperature of patients is decreased (therapeutic hypothermia) to reduce the risk of brain injury and medications to control the arrhythmia. Survivors of sudden cardiac arrest may receive an implantable cardioverter-defibrillator (ICD) (see Preventing Sudden Cardiac Death below).

Common Causes of Sudden Cardiac Arrest

SCD is caused by arrhythmias in the heart. Cardiac Arrhythmias are abnormal heart rhythms. The most common arrhythmia associated with Sudden Cardiac Death is ventricular fibrillation. These cardiac arrhythmias are rapid-firing impulses from the lower chambers of the heart (ventricles). Because of the rapid irregular beating of the ventricles, blood is unable to flow out of the heart. Sudden cardiac arrest presents differently in patients because there are many different causes.

Patients who have previously experienced a heart attack or have coronary artery disease are at high risk for a sudden cardiac arrest. Also, a subset of otherwise healthy individuals has a genetic defect that leads to Sudden Cardiac Death, so people with a family history of SCD may be at high risk.

Symptoms of Sudden Cardiac Arrest

There are no clear symptoms that indicate if a patient is at risk for sudden cardiac arrest. However, individuals with coronary artery disease or heart attack victims should stay educated on sudden cardiac arrest so they can notice any potential changes to their heart rhythm and discuss treatment options with their doctors.

Prior to a sudden cardiac arrest episode, patients may have discomfort in their chest, body weakness, shorter breathing patterns, and palpitations. During a sudden cardiac arrest, patients might feel like their heart is racing or feel dizzy, but the majority of patients do not have any prior symptoms. Signs that a person might be experiencing sudden cardiac arrest are immediately and unexpectedly collapsing, fainting or no pulse, not breathing, and loss of consciousness.

Prevention Sudden Cardiac Death

If a patient is in sudden cardiac arrest, the use of CPR and a defibrillator are the best options to restore the heart’s electrical pattern.

The best sudden cardiac arrest prevention option is for patients at high risk (post-heart attack, known coronary artery disease, known inherited arrhythmia disorders) to discuss potential treatment strategies with their cardiologists. For very high-risk SCD patients, an implantable cardioverter-defibrillator (ICD) is an option. ICD is a small implantable device that is designed to correct irregular heart rhythm by detecting and correcting fast heart rates through the delivery of a powerful electric shock. Additionally, some anti-arrhythmic medications have success in reducing sudden cardiac death.

Cardiovascular Research and Training Institute Sudden Cardiac Arrest Death & Heart Disease (Cardiomyopathy) Research Performed at CVRTI

At the Cardiovascular Research & Training Institute (CVRTI), researchers are interested in understanding the genetic basis for sudden cardiac death disorders and the fundamental mechanisms that trigger the initiation of abnormal heart rhythms in order to prevent Sudden Cardiac Death.

Using Utah’s one-of-its-kind genealogical resource linked to medical records, the Utah Population Database (UPDB), CVRTI investigators are discovering new genes that predispose to Sudden Cardiac Death. By taking a sample of blood, CVRTI investigators can create patient-specific stem cells that can be coaxed into beating heart cells in a dish, so-called induced pluripotent stem cell-derived cardiomyocytes. CVRTI investigators are at the forefront of these new technologies, leveraging them to better understand who is at risk for a Sudden Death disorder, how the abnormal heart rhythms start and how to design new therapies for sudden cardiac arrest.

Continued Research As It Relates to The Heart and Other Organs

Further along the translational spectrum, other CVRTI investigators are exploring how to limit brain and other organ damage once blood flow is stopped. New molecules discovered at the CVRTI have shown promise in reducing the damage to cells from low blood flow (ischemia). Just like therapeutic hypothermia, these agents could be used to reduce catastrophic organ loss once low blood flow has been identified and corrected.