COVID-19-associated cardiogenic shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: : Sara Zand, M.D.[2] Alieh Behjat, M.D.[3]

Synonyms and keywords:: Novel coronavirus, COVID-19, Wuhan coronavirus, coronavirus disease-19, coronavirus disease 2019, SARS-CoV-2, COVID-19, 2019-nCoV, 2019 novel coronavirus, cardiovascular finding in COVID-19, cardiogenic shock, COVID-19 associated cardiogenic shock


SARS-COV-2 or COVID-19 is a specific strain of coronavirus that is responsible for an ongoing global pandemic. COVID-19 may lead to respiratory disease and also multi-organ dysfunction including biventricular failure and profound shock and life threatening cardiogenic shock. Cardiogenic shock shoulb be considered while cardiac ethiology is evident in patients with persistent hypotesion despite fluide resuscitation in the presence of end organs dysfunction. Cardiogenic shock may present as a consequence of cytokine storm pathway or direct invasion of cardiovascular system by virus via ACE2 receptos on the cells. Cardiogenic shock may progress to develop quicky in covid-19 patients and any delay for diagnosis and treatment of such patients will increase mortality rate. In mild or severe types of covid-19 with sudden collapse of hemodynamic, considering different causes of cardiogenic shock including fulminant myocarditis, acute STEMI, massive pulmonary thromboembolism, stress cardiomyopathy, are helpful to clinical approach and quickly initiation of treatment. Mortality rate of covid-19 patients with cardiogenic shock among reported cases in literature was 75% despite use of pharmacological and mechanichal hemodynamic support.

Historical Perspective

To view the historical perspective of COVID-19, click here.



The two most likely mechanisms that contribute to COVID-19 cardiogenic shock are: [5] [6]


Common causes of cardiogenic shock in patients with covid-19 include:[7][8] [9]

Differentiating COVID-19 associated cardiogenic shock from other Diseases

Cardiogenic shock related to COVID-19 must be differentiated from other diseases which include: [10] [11]

Some hemodynamic parameters would help differentiate significant types of shock: [12]

Cardiac Output Pulmonary Capillary Wedge Pressure Systemic Vascular Resistance Pulmonary artery diastolic pressure SVO2
COVID-19-associated cardiogenic shock ↑↔
Septic shock
Hypovolemic shock

Epidemiology and Demographics




Risk Factors

  • There are no established risk factors for COVID-19-associated cardiogenic shock.
  • To view risk factors for the severe form of COVID-19 disease, click here.
  • Moreover, in order to read more on the risk factors of cardiogenic shock, generally, click here.


Natural History, Complications and Prognosis


Diagnostic Study of Choice

cardiac index ≤ 2.2L/min per m². pulmonary capillary wedge pressure ≥ 15 mmHg with impaired organ perfusion including:

History and Symptoms:

Age, sex Cardiovascular history Symptoms Timing according to covid-19 infection Echocardiography, catheterization Covid-19 severity Diagnosis Treatment Outcome
42 years, female Dyslipidemia, oral contraceptive Dyspnea, cough, diarrhea, vomiting, anosmia, dysgeusia suddenly cardiovascular arrest, ventricular arrhythmia storm refractory to antiarrhythmic therapy, sinus rhythm, new LBBB on ECG 12 days Severe biventricular dysfunction in echocardiography, normal epicardial coronary arteries in coronary angiography, no pulmonary thromboembolism in pulmonary angiography Mild Fulminant myocarditis Cardiopulmonary resuscitation at presentation, implantation of VA-ECMO, intra-aortic counter pulsation for unloading left ventricle, temporary pacemaker implantation Refractory shock, death
50 years, male None Severe respiratory distress, severe hypotension with lateral wall ST segments elevation after admission 8 days Severe left ventricular dysfunction with akinesia of the basal and midsegments, apical hypercontractility in echocardiography, Severe bilateral lung pneumonia requiring mechanical ventilation Inverted takotsubo cardiomyopathy Mechanical ventilation, hydroxychloroquine, antiretroviral agents, antibiotics,corticosteroids Survived
75 years, male None Chest pain, dyspnea, inferior STEMI, complete heart block, frequent episodes of ventricular fibrillation requiring cardioversion, intubation, mechanical ventilation 2 days Biventricular failure, predominantly right sided in echocardiography, right coronary artery thrombosis in urgent coronary angiography Severe bilateral SARSE-COV-2 pneumonia STEMI, right coronary artery thrombosis Stenting of right coronary artery Electromechanical dissociation a few hours after PCI, death
37 years, female Obese, history of deep vein thrombosis 8 years ago after fracture and immobilization Dyspnea, chest pain, suddenly developed severe hypotension, S02< 80% 10 days Urgent CT angiography of pulmonary arteries: bilateral pulmonary thromboembolism, right ventricular dilation Patchy peripheral lung opacification Massive pulmonary thromboembolism Systemic thrombolytic therapy Cardiogenic shock, death
53 years, male None Cough, fever, shortness of breath, tachycardia, tachypnea, cool extremities, J point elevation in inferolatel leads of ECG, low cardiac output calculated by Fick index Confimed by PCR 5 week ago, treating with supportive therapy at home LVEF=25%, global hypokinesis, right ventricular dilation with dysfunction in echocardiography, normal epicardial coronary arteries in coronary angiography Mild pulmonary vascular congestion on CXR, normally otherwise Covid-19 induced cardiomyopathy Hydroxychloroquine, isosorbide dinitrate, hydralazine, carvedilol, eplerenone, steroid therapy, inotrope Improving LVEF to 50% after 4 days of therapy, and LVEF 60% after 10 weeks of therapy, survived
30 years, female Obesity Fatigue, shortness of breath, tachycardia, tachypnea, hypotension Confimed by PCR 9 days ago LVEF=45%, moderate diffuse hypokinesis, moderate pericardial effusion Patchy airspace disease in chest CT scan Covid-19 induced cardiomyopathy Hydroxychloroquine, vitamin C, zinc, atorvastatin, milrinone , methylprednisolone Improving LVEF to 55% after 6 weeks of discharge, survived
69 years, male None Cough, shortness of breath, weakness, tachypnea, hypotension, suddenly oxygen desaturation 4 days LVEF=25%, severe diffuse left ventricle hypokinesia Diffuse bilateral interstitial inflammation, subpleural consolidation Covid-19 induced cardiomyopathy Norepinephrine, VA ECMO, IABP, intubation Increased LVEF to narmal value, few hours after weaning of ECMO died of septic shock due to pseudomonas ,klebsiella

Physical Examination

Laboratory Findings

  • In addition, the increase of some biomarkers demonstrates poor prognosis, increased mortality, and more severe symptoms in COVID-19 patients:[19]



Echocardiography or Ultrasound

CT scan

  • Generally, aCT scan is not suggested as a primary imaging study for evaluating a case of cardiogenic shock related to COVID-19. However, it can useful for observing coexisting ARDS by demonstrating a ground-glass opacity.[21]

To view the CT scan findings on COVID-19, click here.


Other Imaging Findings

  • To view other imaging findings on COVID-19, click here.

Other Diagnostic Studies

  • To view other diagnostic studies for COVID-19, click here.


Cardiogenic shock medical therapy:

The maistay of therapy of cardiogenic shock in covid-19 patients is respiratory and circulatory support.[7]

Mechanical Support:

  • In treating patients with cardiogenic shock related to COVID-19, the efficacy of extracorporeal membrane oxygenation (ECMO) is indistinct, however it may be used in the most critically ill and highly selective patients.
  • Although specialists implicate ECMO and mechanical circulatory support devices in severe cased of COVID-19 related cardiogenic shock, the mortality rate if high in those patients who undergo this treatment.
  • It has been reported in a case series from China, that most of these patients had a poor prognosis and did not survive despite implicating ECMO. [24] [16]


Primary Prevention

For primary preventive measures of COVID-19, click here.

Secondary Prevention

  • There are no established measures for the secondary prevention of COVID-19-associated myocarditis.

For secondary preventive measures of [COVID-19], click here.


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