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单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Cardiogenic Shock,Nick Tehrani, MD,Cardiogenic ShockNick Tehrani,Definition,90 mmHg,15 mmHg,Definition90 mmHg 65,?,Female gender,?,Large infarction,?,Anterior infarction,?,Prior infarction,?,DM,?,Prior HTN,Risk Factors for Cardiogenic S,Post-mortem study of Shock hearts,?,At least 40% of the myocardium infarcted,in the aggregate (old and new injury),?,80% have significant LAD disease,?,2/3 have severe 3Vdz,Post-mortem study of Shock hea,Outcomes of Cardiogenic Shock,?,Historic mortality 60-80%,?,More recently reported mortality numbers,?,67% in the SHOCK trial registry,?,56% in GUSTO-I,(v.s. 3% in Pts. without shock),Outcomes of Cardiogenic Shock?,Outcomes of Cardiogenic Shock,?,The ST pattern in Cardiogenic shock:,?,15-30 %,?,Non-ST elevation MI,?,Older,?,Mortality: 77%,?,70-85%,?,ST elevations MI/ New LBBB,?,Mortality: 53-63%,SHOCK registry findings on this point,Outcomes of Cardiogenic Shock?,Outcomes of Cardiogenic Shock,The SHOCK registry,?,Similar mortality,in the two groups,?,62.5% in non-ST elevation,?,60.4% with ST elevation,Outcomes of Cardiogenic ShockT,Pathophysiology of Shock,?,Effect of Hypotension,?,Flow in,normal coronary:,?,Regulated by microvascular resistance,?,Coronary flow may be preserved at AO,pressures as low as 50 mm Hg,?,In coronary vessel with,critical stenosis:,?,Vasodilator reserve of microvascular bed is,exhausted,?,Decrease in AO pressure = Coronary,hypoperfusion,Pathophysiology of Shock?Effec,Pathophysiology of Shock,Effect of Hypotension (continued),Normal heart extracts 65% of the O2 present in,the blood,?,Little room for augmentation of O2 extraction,Pathophysiology of ShockEffect,Pathophysiology of Shock,Effect of:,LVEDP,(mm Hg),Elevated LVEDP,on coronary flow,Pathophysiology of ShockEffect,Pathophysiology of Shock,Hypotension + LVEDP and critical stenosis,?,Myocardial Hypoperfusion,?,LV,dysfunction,?,Systemic lactic acidosis,?,Impairment of non-ischemic myocardium,?,worsening hypotension.,Pathophysiology of ShockHypote,Schematic,?,LVEDP elevation,?,Hypotension,?,Decreased coronary,perfusion,?,Ischemia,?,Further myocardial,dysfunction,?,Neurohormonal,activation,?,Vasoconstriction,?,Endorgan hypoperfusion,Schematic?LVEDP elevation?Hypo,Medical Stabilization of Shock Pts.,?,?,?,?,Figure out the volume status, Swan if in doubt,Air way,Judicious afterload reduction,Maintain A,V synchrony,?,Dont tolerate Afib,?,Dual chamber pacing if A-V block present,?,Correct Acid-Base disturbances,?,Maintain BP (,?,IABP and/or Pressors).,Medical Stabilization of Shock,Physiologic Effect of IABP in-vivo,?,Decreased afterload,?,LV O2 consumption,Williams, et.al., Circulation 1982,?,Kern, et.al.,Circulation 1993,?,Coronary blood flow velocity was measured using doppler-,wire in nine patients with critical stenotic lesions.,?,Peak diastolic coronary flow velocity beyond the stenosis was,unaffected by intra-aortic balloon pumping,.,?,There was unequivocal IABP-mediated augmentation of both,proximal and distal coronary blood flow velocities post PTCA.,Physiologic Effect of IABP in-,Physiologic Effect of IABP in-vivo,?,Fuchs, et.al.,Circulation, 1983,?,Great cardiac vein flow was measured in seven patients,receiving maximal drug therapy and requiring balloon pumping,for unstable angina.,?,All,patients had greater than 90% stenosis of the proximal LAD,coronary artery.,?,Increased great cardiac vein flow correlated with increased,mean aortic,diastolic pressure across changes in balloon,volumes (off, 20 cc, 30 cc,and 40 cc) and changes in assist,ratio (off, 1:4, 1:2, and 1:1) (p = .02).,Physiologic Effect of IABP in-,Physiologic Effect of IABP in-vivo,Thus,balloon pumping increased flow to,a bed fed by the,critical stenosis, or,collateral vessels,Physiologic Effect of IABP in-,IABP in Acute MI,JACC 1985,IABP in Acute MIJACC 1985,IABP in Acute MI,?,?,?,?,Pre-thrombolytic era,No Lytics, ASA, or Lopressor,20 patients with Acute MI and,“extensive myocardium at,risk per baseline Thalium”,were Randomized.,Pt.s in,Shock,were,excluded,Std. Rx:,O2, MSo4, Lido,Heparin,Std Rx,+,IABP Plus IV NTG,IABP in Acute MI?Pre-thromb,IABP in Acute MI,?,?,Patients had repeat Thalium scan on Day-4,No differences were observed between the two,groups regarding:,-Thalium defect score comparing days 1 and 4,-The ejection fraction comparing days 1 and 4,=,“,Unlikely that a mortality benefit is conferred,by the IABP/NTG combination”,IABP in Acute MI?Patients had,Utility of IABP in Shock Pts,.,?,Observed clinical benefits:,?,?,?,?,Improved acid-base status,Improved urine output,Improved mentation,Improved overall hemodynamics,All this, however, does not add up,to improved survival,without,Flow Restoration,Utility of IABP in Shock Pts.?,Thrombolysis in Cardiogenic Shock,?,Rates of,Reperfusion,Lower,and,?,Rates of,Reocclusion,Higher,Than in,non-shock,pts,Possible Reason,:,Diffusion of,thrombolytic agent,into the thrombus may,be,PRESSURE DEPENDENT.,Thrombolysis in Cardiogenic Sh,BP Effect on efficacy of lytics in Shock,Dog data,?,LAD occlusion by,thrombus,?,Hypotension,induced by,phlebotomy,Prewitt,JACC 1994; 23:784,BP Effect on efficacy of lytic,Any Randomized Trials of,Thrombolysis in Cardiogenic Shock?,?,Most thrombolytic trials specifically excluded,patients in cardiogenic shock,?,The only large placebo-controlled thrombolytic study,specifically examining Pts. presenting with shock,was,GISSI-1,?,Streptokinase,=,No Benefit,Any Randomized Trials ofThromb,Combined IABP and Thrombolysis,Observational,Data:,GUSTO-I:,IABP in 62 of the 310 lytic,Rxd Pts. in shock,Combined IABP and Thrombolysis,Combined IABP and Thrombolysis,?,Kovack, et. al., JACC 2019,?,Stomel, et. al., Chest 1994,Two,retrospective observational,series from community,hospitals:,Improved survival,from combination Rx.,Combined IABP and Thrombolysis,Combined IABP and Thrombolysis,Observational,Data from SHOCK Registery,:,Combined IABP and Thrombolysis,Combined IABP and Thrombolysis,-,Barron, et.al., AHJ June 2019,-National Registry of MI-2, Data base,-21,178 pts. Presenting with or developing post-MI shock,-32% Received IABP,P,Selection Bias,TT,PPTCA,PPTCA,IABP,IABP,Combined IABP and Thrombolysis,Combined IABP and Thrombolysis,Accompanying Editorial by Magnus Ohman, and,Judith Hochman:,“Although, there is a wealth of physiologic and,outcomes data to support the use of early IABP,therapy in cardiogenic shock (in conjunction,with lytics), randomized trials are clearly,needed.”,Combined IABP and Thrombolysis,Combined IABP and Thrombolysis,The only,randomized,trial on the subject:,Thrombolysis and Counterpusion to Improve,Cardiogenic Shock Survival,(TACTICS),: Results,of a,Prospective Randomized Trial,.,Magnus Ohman, et.al.,Circulation Oct. 2000 Supp. Abstract,Combined IABP and Thrombolysis,TACTICS,?,?,ST elevation MI patients, presenting within 12,hours of Sx, and Cardiogenic shock,57 Patients were randomized,Thrombolytic,Therapy alone,Thrombolytic,Therapy,+,IABP,TACTICS?ST elevation MI patie,TACTICS,?,The,primary endpoint,of 6 month mortality,was not,statistically significant, P=0.3,Subgroup analysis:,For KILLIP classes III and IV, P=0.07,?,TACTICS?The primary endpointof,PATIENT IS IN SHOCK w/ ST elevations,and 12 hrs Sx onset,If,EARLY REV,ASCULARIZATION,is not to be pursued:,Administration of Lytics,should not be delayed,in anticipation of placement of IABP,despite,lack of randomized data,proving efficay.,?,IABP,?,Pressors,May,increase the efficacy of Lytics,PATIENT IS IN SHOCK w/ ST elev,SHOCK Trial,Whether,EARLY REV,ASCULARIZATION,improves survival among,patients with,cardiogenic shock,?,SHOCK TrialWhetherEARLY REVASC,SHOCK Trial,302 Pts. with ST elevation,(or new LBBB) and,cardiogenic shock,?,Within,36 hrs,. of,MI onset,?,Within,12 hrs,. of,Shock onset,Immediate Revascularization,(CABG/PTCA),Late revascularization (if indicated),deferred for at least 54 hours,SHOCK Trial302 Pts. with ST el,SHOCK Trial:,Primary end point, 30 days mortality,66.4%,70,60,56%,47%,50%,63%,52.4%,M,o,r,t,a,l,i,t,y,50,40,30,20,10,0,Revasc.,Med Rx,30 days,6 Months,12 Months,Diff.=9%,P=0.11,Diff.=13%,P=0.027,Diff.=14%,P0.02,SHOCK Trial: Primary end point,SHOCK Trial,Why wasnt the Primary end,-point met?,?,Low mortality in the,initial medical mgt,gp.,?,High rates of,?,IABP use, 86%,?,TT use, 63%,?,Delayed,revasculariztion, 21%,?,Median of,104 hrs,post randomization,56%,56,54,52,50,48,46,44,42,Early Revasc,Medical Mgt,47%,30 days mortality,SHOCK TrialWhy wasnt the Prim,SHOCK Trial:,Subgroup analysis, Age less than 75,65%,70,60,66.7%,56%,41%,45%,48.4%,Revasc.,Med Rx,M,o,r,t,a,l,i,t,y,50,40,30,20,10,0,30 days,6 months,12 Months,P=0.02,CI1.0,P=0.002,CI1.0,P0.02,CI 1.0),?,6 months( CI 1.0),?,12 months, no difference in outcome,SHOCK Trial: What to do with P,What to do with Pt.s older than 75,?,SHOCK Registry,results is,in contrast,to the,SHOCK Trial,findings in this subgroup.,?,Those older than 75 y.o., selected to undergo ERV had a,survival advantage,.,?,Case by case assessment,in this population, and,not,across the board exclusion,is called for,.,What to do with Pt.s older tha,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,?,SHOCK Trial:,Revascularization,(N=152),Medical Treatment,(N=150),IIb/IIIa,Antagonist,41.7%,25%,Stent,Placement,35.7%,52.3%,Role of IIb/IIIa Inhibitors an,Role of IIb/IIIa inhibitors in Cardiogenic Shock,?,Retrospective subgroup analysis from the PURSUIT trial,Hassade, et.al., JACC, 2000,?,Randomization to eptifibatide,did not affect the incidence,of shock,?,Patients randomized to eptifibatide who developed shock,had a,significantly reduced incidence of death at 30 days,?,A possible mechanism of benefit is,relief of microvascular,obstruction,Role of IIb/IIIa inhibitors in,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,Long-Term Mortality Benefit With the,Combination of Stents and,Abciximab,for,Cardiogenic Shock Complicating Acute,Myocardial Infarction,Coronary Artery Disease,Chan, Albert W. MD, MS; Chew, Derek P. MBBS;,Bhatt, Deepak L. MD; Moliterno, David J. MD;,Topol, Eric J. MD; Ellis, Stephen G. MD,AJC Jan. 15, 2019,Role of IIb/IIIa Inhibitors an,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,?,Single center, non-randomized,?,Data collected: Jan.1993 and June 2000,?,Thirty month follow-up available,96 Pt.s w/,Cardiogenic Shock,Stent + Reopro,N=27,Stent Only,N=14,PTCA+Reopro,N=18,PTCA Only,N=37,Role of IIb/IIIa Inhibitors an,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,T,h,i,r,t,y,d,a,y,M,o,r,t,a,l,i,t,y,R,a,t,e,s,(,%,),70,60,50,40,30,20,10,0,On Univariate analysis,:,Absence of Stent use:,HR 2.39, 95% CI 1.22 to 4.67, p = 0.01,East,Absence of Abciximab use:,HR 1.95, 95% CI 1.03 to 3.71, p = 0.04,Stent+,Reopro,Stent,Only,PTCA+,PTCA,Reopro,Only,EF =30%,HR 3.44, 95% CI 1.35 to 8.78, p = 0.01,Role of IIb/IIIa Inhibitors an,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,At 30 months,Use of Stents,?,29% Absolute mortality reduction,?,1 additional life saved for each 3-4,treated Patients.,Abciximab +Stenting,?,10% Absolute mortality reduction,?,1 additional life saved for each,10 patients treated.,Role of IIb/IIIa Inhibitors an,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,Results of Primary Percutaneous Transluminal,Coronary Angioplasty Plus,Abciximab,With or,Without Stenting for Acute Myocardial Infarction,Complicated by Cardiogenic Shock,Coronary Artery,DiseaseGiri, Satyendra MD, MPH, MRCP; Mitchel, Joseph,DO; Azar, Rabih R. MD, MSc; Kiernan, Francis J. MD; Fram,Daniel B. MD; McKay, Raymond G. MD; Mennett, Roger,MSc; Clive, Jonathan PhD; Hirst, Jeffrey A. MD, MS,AJC,15 January 2019,.,Role of IIb/IIIa Inhibitors an,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,?,This was a nonrandomized, prospective observational,study.,?,113 (13.9%) were diagnosed with cardiogenic shock,from 8/95 to 8/99.,Role of IIb/IIIa Inhibitors an,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,No Reopro,With Reopro,Role of IIb/IIIa Inhibitors an,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,Multivariate Analysis,Role of IIb/IIIa Inhibitors an,Role of IIb/IIIa Inhibitors and Stents in,Cardiogenic Shock,Speculation:,Greater use of Abxicimab, and Stents in the SHOCK,Trial may well have resulted in a positive primary,endpoint.,The age cutoff of 75 may or may not have retained its,significance vis-,-vis increased mortality.,Role of IIb/IIIa Inhibitors an,Reversal of Cardiogenic Shock by Percutaneous,Left Atrial-to-Femoral Arterial Bypass Assistance,?,Holger, et.al,Circulation.,2019;104:2917.,?,V,ADs,were implanted in 18 consecutive,patients who had cardiogenic,shock after,myocardial infarction,?,A 21F venous,cannula into the left atrium,by transseptal puncture using TEE,?,Pts served as their own controls,?,All hemodynamic parameters showed,significant improvement,?,“The influence,of this device on long-term,prognosis warrants further investigation,.”,Reversal of Cardiogenic Shock,Take Home Points,?,Combining Reopro,with Stenting,is likely,to,enhance the benefit of early revascularization.,?,IABP helpful in stabilizing the Pt.,?,Mitigates clinical signs of SHOCK,?,May,improve outcome with concurrent Lytics,?,No definitive evidence,(randomized trials),showing,improved outcomes with IABP/Lytic combinaiton.,Take Home Points?Combining Reo,Take Home Points,?,Nothing magical about the age cut off of 75, case,by case assessment in this population is called for.,?,If pt.,is not a candidate for early revascularization,but is within12 hrs. of MI onset, administration of,lytics (subject to risk-benefit assessment, age,grafts,),should not be delayed,in anticipation of,placement of IABP.,Take Home Points?Nothing magic,
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