- Paper Report
- Open Access
Novel therapy for cardiogenic shock
- Naresh Ramakrishnan1
© Current Science Ltd 2000
- Published: 22 May 2000
- Cardiogenic shock
A study to assess the safety and efficacy of L-NMMA in the treatment of cardiogenic shock.
. Eleven consecutive patients with extensive AMI complicated by cardiogenic shock
. All mechanically ventilated/IABP
. Coronary angiography + primary percutaneous transluminal coronary angioplasty when feasible
. All commenced on dopamine/dobutamine/frusemide infusions
. Cardiogenic shock defined as persistent unaugmented systolic BP < 100 mm Hg, accompanied by pulmonary congestion (on chest X-ray), cardiac index (CI) < 2.5 L/min/m2 and wedge pressure > 15 mm Hg despite therapy.
. Patients with tachyarrhythmia/bradyarrhythmia, mechanical complication, fever > 38o C, creatinine > 200 ?mol/mL
. L-NMMA was administered intravenously, initially as bolus of 1 mg/kg then as an infusion of 1 mg/kg/h for 5 h.
Within 10 min mean arterial pressure (MAP) increased from 76 ? 9 to 109 ? 22 mm Hg. CI initially fell from 2.0 ? 0.5 to 1.7 ? 0.4 L/min/m2; however, after discontinuation it rose to 1.85 ? 0.4 L/min/m2. Urine output (UO) increased by 148%. The positive changes in MAP and UO persisted after 24 h. Ten of the eleven patients were weaned off ventilation and IABP; eight were discharged from the coronary care unit and seven were alive at the 1 month follow-up.
Trials of L-NMMA in septic shock have been disappointing, and interestingly there was an alarming amount of electrocardiographic evidence of myocardial ischaemia. (Mayr et al Crit Care Med 1996, 24:1930-1930 and Grover et al, Crit Care Med 1999, 27:913-922). The 1999 Nobel prize in medicine was awarded to Drs Robert%20Furchgott, Louis%20Ignarro, and Ferid%20Murad for their discoveries that vascular endothelial cells make NO and that NO stimulates cyclic-guanosine monophosphate synthesis in the smooth muscle cells, causing relaxation. This is controlled by endothelial NO synthetase.