1、Cardiogenic ShockNick Tehrani,MDDefinition90 mmHg15 mmHgSHOCK RegistryJACC Sept.2000,Supp.ASpectrum of Clinical PresentationsMortalityRespiratoryDistressHypotensionHypoperfusion1.4%21%22%70%60%5.6%28%65%Risk Factors for Cardiogenic Shock Due to AMI-mediated LV Dysfunction?Age 65?Female gender?Large
2、infarction?Anterior infarction?Prior infarction?DM?Prior HTNPost-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 3VdzOutcomes of Cardiogenic Shock?Historic mortality 60-80%?More recently reporte
3、d mortality numbers?67%in the SHOCK trial registry?56%in GUSTO-I(v.s.3%in Pts.without 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 pointOutcomes
4、 of Cardiogenic ShockThe SHOCK registry?Similar mortalityin the two groups?62.5%in non-ST elevation?60.4%with ST elevationPathophysiology 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
5、 coronary vessel with critical stenosis:?Vasodilator reserve of microvascular bed is exhausted?Decrease in AO pressure=Coronary hypoperfusionPathophysiology of ShockEffect of Hypotension(continued)Normal heart extracts 65%of the O2 present in the blood?Little room for augmentation of O2 extractionPa
6、thophysiology of ShockEffect of:LVEDP(mm Hg)Elevated LVEDPon coronary flowPathophysiology of ShockHypotension +LVEDP and critical stenosis?Myocardial Hypoperfusion?LV dysfunction?Systemic lactic acidosis?Impairment of non-ischemic myocardium?worsening hypotension.Schematic?LVEDP elevation?Hypotensio
7、n?Decreased coronaryperfusion?Ischemia?Further myocardialdysfunction?Neurohormonal activation?Vasoconstriction?Endorgan hypoperfusionMedical Stabilization of Shock Pts.?Figure out the volume status,Swan if in doubtAir wayJudicious afterload reductionMaintain AV synchrony?Dont tolerate Afib?Dual cham
8、ber pacing if A-V block present?Correct Acid-Base disturbances?Maintain BP (?IABP and/or Pressors).Physiologic Effect of IABP in-vivo?Decreased afterload?LV O2 consumptionWilliams,et.al.,Circulation 1982?Kern,et.al.,Circulation 1993?Coronary blood flow velocity was measured using doppler-wire in nin
9、e 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-viv
10、o?Fuchs,et.al.,Circulation,1983?Great cardiac vein flow was measured in seven patients receiving maximal drug therapy and requiring balloon pumpingfor unstable angina.?Allpatients had greater than 90%stenosis of the proximal LAD coronary artery.?Increased great cardiac vein flow correlated with incr
11、eased mean aorticdiastolic 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-vivoThusballoon pumping increased flow to a bed fed by thecritical stenosis,or collateral vesselsIABP in Acute MIJACC
12、1985IABP in Acute MI?Pre-thrombolytic eraNo Lytics,ASA,or Lopressor20 patients with Acute MI and“extensive myocardium at risk per baseline Thalium”were Randomized.Pt.s in Shock were excludedStd.Rx:O2,MSo4,Lido,HeparinStd Rx+IABP Plus IV NTGIABP in Acute MI?Patients had repeat Thalium scan on Day-4No
13、 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 conferredby the IABP/NTG combination”Utility of IABP in Shock Pts.?Observed clinical benefits:?Improved acid-bas
14、e statusImproved urine outputImproved mentationImproved overall hemodynamicsAll this,however,does not add upto improved survivalwithout Flow RestorationThrombolysis in Cardiogenic Shock?Rates of Reperfusion Lower,and?Rates of Reocclusion HigherThan in non-shock ptsPossible Reason:Diffusion of thromb
15、olytic agent into the thrombus may be PRESSURE DEPENDENT.BP Effect on efficacy of lytics in ShockDog data?LAD occlusion by thrombus?Hypotension induced by phlebotomyPrewittJACC 1994;23:784Any Randomized Trials ofThrombolysis in Cardiogenic Shock?Most thrombolytic trials specifically excluded patient
16、s in cardiogenic shock?The only large placebo-controlled thrombolytic study specifically examining Pts.presenting with shock was GISSI-1?Streptokinase=No BenefitCombined IABP and ThrombolysisObservational Data:GUSTO-I:IABP in 62 of the 310 lyticRxd Pts.in shockCombined IABP and Thrombolysis?Kovack,e
17、t.al.,JACC 2019?Stomel,et.al.,Chest 1994Two retrospective observationalseries from community hospitals:Improved survivalfrom combination Rx.Combined IABP and ThrombolysisObservationalData from SHOCK Registery:Combined IABP and Thrombolysis-Barron,et.al.,AHJ June 2019-National Registry of MI-2,Data b
18、ase-21,178 pts.Presenting with or developing post-MI shock-32%Received IABPP Selection BiasTTPPTCAPPTCAIABPIABPCombined IABP and ThrombolysisAccompanying 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
19、 in cardiogenic shock(in conjunction with lytics),randomized trials are clearly needed.”Combined IABP and ThrombolysisThe 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.,C
20、irculation Oct.2000 Supp.AbstractTACTICS?ST elevation MI patients,presenting within 12 hours of Sx,and Cardiogenic shock57 Patients were randomizedThrombolyticTherapy aloneThrombolyticTherapy +IABPTACTICS?The primary endpoint of 6 month mortality was notstatistically significant,P=0.3Subgroup analys
21、is:For KILLIP classes III and IV,P=0.07?PATIENT IS IN SHOCK w/ST elevations,and 12 hrs Sx onsetIf EARLY REVASCULARIZATIONis not to be pursued:Administration of Lytics should not be delayedin anticipation of placement of IABPdespite lack of randomized data proving efficay.?IABP?PressorsMayincrease th
22、e efficacy of LyticsSHOCK TrialWhetherEARLY REVASCULARIZATIONimproves survival amongpatients with cardiogenic shock?SHOCK Trial302 Pts.with ST elevation(or new LBBB)and cardiogenic shock?Within 36 hrs.of MI onset?Within 12 hrs.of Shock onsetImmediate Revascularization(CABG/PTCA)Late revascularizatio
23、n(if indicated)deferred for at least 54 hoursSHOCK Trial:Primary end point,30 days mortality66.4%706056%47%50%63%52.4%Mortality50403020100Revasc.Med Rx30 days6 Months12 MonthsDiff.=9%P=0.11Diff.=13%P=0.027Diff.=14%P0.02SHOCK TrialWhy wasnt the Primary end-point met?Low mortality in the initial medic
24、al mgt gp.?High rates of?IABP use,86%?TT use,63%?Delayed revasculariztion,21%?Median of 104 hrspost randomization56%5654525048464442Early RevascMedical Mgt47%30 days mortalitySHOCK Trial:Subgroup analysis,Age less than 7565%706066.7%56%41%45%48.4%Revasc.Med RxMortality5040302010030 days6 months12 Mo
25、nthsP=0.02CI1.0P=0.002CI1.0P0.02CI 1.0)?6 months(CI 1.0)?12 months,no difference in outcomeWhat 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 as
26、sessmentin this population,and not across the board exclusionis called for.Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock?SHOCK Trial:Revascularization(N=152)Medical Treatment(N=150)IIb/IIIaAntagonist41.7%25%Stent Placement35.7%52.3%Role of IIb/IIIa inhibitors in Cardiogenic Shock?Retro
27、spective subgroup analysis from the PURSUIT trialHassade,et.al.,JACC,2000?Randomization to eptifibatide did not affect the incidenceof 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
28、microvascular obstructionRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockLong-Term Mortality Benefit With the Combination of Stents and Abciximab for Cardiogenic Shock Complicating Acute Myocardial InfarctionCoronary Artery DiseaseChan,Albert W.MD,MS;Chew,Derek P.MBBS;Bhatt,Deepak L.MD;Mo
29、literno,David J.MD;Topol,Eric J.MD;Ellis,Stephen G.MDAJC Jan.15,2019Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock?Single center,non-randomized?Data collected:Jan.1993 and June 2000?Thirty month follow-up available96 Pt.s w/Cardiogenic ShockStent+ReoproN=27Stent OnlyN=14PTCA+ReoproN=18P
30、TCA OnlyN=37Role of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockThirty day Mortality Rates(%)706050403020100On Univariate analysis:Absence of Stent use:HR 2.39,95%CI 1.22 to 4.67,p=0.01EastAbsence of Abciximab use:HR 1.95,95%CI 1.03 to 3.71,p=0.04Stent+ReoproStentOnlyPTCA+PTCA ReoproOnlyEF=30
31、%HR 3.44,95%CI 1.35 to 8.78,p=0.01Role of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockAt 30 monthsUse of Stents?29%Absolute mortality reduction?1 additional life saved for each 3-4treated Patients.Abciximab+Stenting?10%Absolute mortality reduction?1 additional life saved for each10 patients t
32、reated.Role of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockResults of Primary Percutaneous Transluminal Coronary Angioplasty Plus Abciximab With or Without Stenting for Acute Myocardial Infarction Complicated by Cardiogenic ShockCoronary Artery DiseaseGiri,Satyendra MD,MPH,MRCP;Mitchel,Joseph
33、 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,MSAJC,15 January 2019.Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock?This was a nonrandomized,prospective observational study.?113(13.9%)were diagnose
34、d with cardiogenic shock from 8/95 to 8/99.Role of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockNo ReoproWith ReoproRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockMultivariate AnalysisRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockSpeculation:Greater use of Abxicimab,an
35、d 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.Reversal of Cardiogenic Shock by Percutaneous Left Atrial-to-Femoral Arterial Bypass Assistance?Holger,et.al,Circulation.20
36、19;104:2917.?VADswere implanted in 18 consecutive patients who had cardiogenicshock after myocardial infarction?A 21F venouscannula 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
37、 device on long-term prognosis warrants further investigation.”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?Mayimprove outcome with concurrent Lytics?No definitive ev
38、idence(randomized trials)showing improved outcomes with IABP/Lytic combinaiton.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.
