083105_CARDIOGENICSHOCK-8-31-05-MEDICINE

Cardiogenic Shock:

Cardiogenic Shock Definition Heart’s inability to meet metabolic needs Hypotension (SBP <80-90); cold, clamy and pale extremities; cyanosis, altered mentation, oliguria. CI <2.2 l/min/m 2 , PCWP >18 mmH, lactate >1.5 mM/l.

Types of Shock :

Types of Shock Hypovolemic, the most common Cardiogenic - systolic dysfx/mechanical dysfx - Obstructive - cardiogenic Tamponade, LA myxoma, LA thrombus, PE Distributive Sepsis, anaphylaxis, DOD, spinal shock

Pathophysiology:

Pathophysiology Circulation 2003;107:2998

Systemic Inflammatory Response:

Systemic Inflammatory Response Pts with large MIs have LGT and  WBC  serum complement, interleukins, and CRP  inducible nitric oxide synthetase (iNOS)  nitric oxide and peroxynitrite levels Circulation 2003;107:2998

High NO and Peroxynitrite Levels :

High NO and Peroxynitrite Levels Direct inhibition of myocardial contractility  mitochondrial respiration in non-ischemic cells  glucose metabolism  pro-inflammatory effects  cathecolamine sensitivity   systemic vasodilation Circulation 2003;107:2998

Cardiogenic Shock:

Cardiogenic Shock Causes Post-MI LV failure 85% STEMI  70% NSTEMI  15% RV MI 3% - 4% Severe MR 7% - 8% Post-MI-VSD 3% - 4% Free wall rupture/tamponade 2% - 3% Shock Trial Registry

Cardiogenic Shock:

Cardiogenic Shock Prognosis Overall in-hospital mortality 60% Higher mortality in early CS (<24 hours) Similar mortality in pts with STEMI vs NSTEMI Higher mortality in those with mechanical complications vs pump failure Higher mortality in elderly (>75), women, DM CS Trial Registry: Am J Med 2000;108:374

Cardiogenic Shock:

Cardiogenic Shock Prognosis 40% periop mortality in those with severe MR 95% mortality in those with unoperated VSD 80% mortality in those with operated VSD CS Registry: Am J Med 2000;108:374

Cardiogenic Shock:

Cardiogenic Shock Timing On arrival: 10%-15% In hospital: 85%-90% Median of 6 hours after AMI Early shock (<24 hours) in 75% Shock Trial Registry

Cardiogenic Shock:

Cardiogenic Shock Non-ST-elevation MI (17%) More common in patients >65 y/o Prior MI, heart failure, CABG, or PVD More often have 3 vessel CAD Post-MI angina or MI extension are common Shock Trial Registry

Cardiogenic Shock:

Cardiogenic Shock Post-MI acute severe MR (7% - 8%) Occurs early (median 13 hours) More common in women More common with infero-posterior MI More common with NSTEMI (60% vs 40%) Shock Trial Registry

Cardiogenic Shock:

Cardiogenic Shock Post-MI VSD (4% - 5%) Occurs early (median of 16 hours) More common in those >65 y/o More common in women Twice more common if no DM or prior MI Most common in RCA or LAD - MIs (88%) Shock Trial Registry

Cardiogenic Shock:

Cardiogenic Shock Post-MI free wall rupture/tamponade (2% - 3%) More common with STEMI More common without prior MI More common without diabetes Shock Trial Registry

Cardiogenic Shock:

Cardiogenic Shock Causes in patients post-CABG/VR Ischemia or MI Prolonged bypass/reperfusion injury Tamponade (frequently localized) Prosthesis dehiscence or thrombus

Cardiogenic Shock:

Cardiogenic Shock Uncommon causes Infective endocarditis (acute MR/AR) Aortic dissection (AR, tamponade, ischemia) Cardiac trauma (papillary muscle rupture/MR,TR) Acute massive PE Severe myocarditis Rarely, AS/MS/HOCM

Cardiogenic Shock – Patients at risk:

Cardiogenic Shock – Patients at risk Age >65 y/o Women Previous angina, MI, CHF DM Stroke or PVD Persistently occluded IRA LAD-MI Multivessel CAD LVEF <35% High CPK-MB/troponin

Cardiogenic Shock:

Cardiogenic Shock General measures Team approach - be the leader Start Rx before full evaluation completed Assess volume, ventilation, pump function Restore/maintain sinus rhythm Correct acid-base abnormalities Improve O 2 carrying capacity (Hct > 33) “CARDIAC CATH - REVASCULARIZE”

Cardiogenic Shock:

Cardiogenic Shock LV and RV function and mechanics Beside echocardiography LV and RV ejection fraction LV and RV wall motion MR, VSD, pseudoaneurysm Pericardial effusion/tamponade

Pharmacotherapy:

Pharmacotherapy

Cardiogenic Shock - Pharmachotherapy:

Cardiogenic Shock - Pharmachotherapy

Cardiogenic Shock:

Cardiogenic Shock Pharmacotherapy Phosphodiesterase inhibitors amrinone: 0.75-3 mg/kg, 5-10 ug/kg/min milrinone: 20 ug/kg over 10’ then 0.5 ug/kg/min Dobutamine, fluids, A-V pacing in RV-MI Do not use digoxin

Cardiogenic Shcok:

Cardiogenic Shcok Nitric oxide synthase inhibitor (L-NAME) Dose: 1mg/Kg bolus, 1mg/Kg/hour x 5 hours  vasodilation  mean arterial pressure  CO after transient decrease  urine output,  time on IABP/mechanical ventilation  mortality at 1 month Does not affect LV systolic or diastolic fx Eur Heart J 2003;24:1287; Circulation 2000;101:1358

Cardiogenic Shock:

Cardiogenic Shock Levosimendan (infusion – 0.1 ug/kg/minx24 h) Calcium sensitizer  contractility without  in intracellular Ca or c-AMP Vasodilator, open ATP sensitive K channels Compared to or in addition to cathecolamines, improves hemodynamics and 1, 6 month mortality and less arrhythmogenic Ital Heart J 2003;suppl2:34s; Acta Anaesthesiol Scand 2003;47:1251;

Cardiogenic Shock:

Cardiogenic Shock Intraaortic Balloon Pump Improves survival (40% to 60%) if used with lytics/PCI/CABG/VR Used in >80% of patients undergoing PCI/CABG Similar benefit when compared to VADs

Cardiogenic Shock:

Cardiogenic Shock Thrombolytic therapy Success rate of lytics is low (30-50%) Improves survival up to 60% if successful TPA and SK have similar efficacy Higher rate of wall rupture in pts > 75 y/o

Cardiogenic Shock:

Cardiogenic Shock Coronary angiography Performed in  60% of patients 3 vessel CAD: 50% - 55%, 1-2 vessel CAD:20% -25%, and > 50% left main: 15% - 20% LAD culprit vessel in 40% of pts LAD or RCA culprit vessel in those with VSD RCA culprit vessel in pts with severe MR/RV-MI Cx culprit in those with free wall rupture Shock Trial Registry

Cardiogenic Shock:

Cardiogenic Shock Percutaneous Coronary Interventions Low use ( 30 %) and lower success rate (  75%) than in those without cardiogenic shock  success and survival when stents, 2b/3a inhibitors, and asa & clopidogrel used  survival when done within 16 hrs  success in pts <70 y/o, 1 vessel CAD, no previous MI, and had no lytic Rx  survival with TIMI 3 flow

Cardiogenic Shock:

Cardiogenic Shock CABG Only 12-50% of pts undergo CABG Half of pts have had lytics, IABP, or PCI High perioperative/overall mortality (40-50%) Lower mortality for MR/VSD (30%/40%) Highest mortality in pts with LAD, 3V CAD or >70 years old

Cardiogenic Shock:

Cardiogenic Shock

Cardiogenic Shock:

Cardiogenic Shock

Cardiogenic Shock: ERV vs IMS:

Cardiogenic Shock: ERV vs IMS N Engl J Med 1999;341:625 56% vs 47%, p = 0.11

Cardiogenic Shock: ERV vs IMS:

Cardiogenic Shock: ERV vs IMS JAMA 2001;285:190 53% vs 66%, p = 0.03

Slide 34:

N Engl J Med 1999;341:625

Cardiogenic Shock - Therapy:

Cardiogenic Shock - Therapy Circulation 2003;107:2998