controversies in cardiogenic shock · cardiogenic shock trials • iab shock 2 trial — •...

Controversies in Cardiogenic Shock

Timothy D. Henry, MD Cedars-Sinai Heart Institute

Key Issues • Cardiac Arrest-Cardiogenic shock

interaction • New SCAI Classification • Refractory Shock • Shock with Multivessel disease • Shock centers and teams

Interaction of Cardiac Arrest and Cardiogenic Shock

Cardiogenic Shock

(+)

Cardiogenic Shock

(­–) C

ardi

ac

Arre

st

(+)

184 Patients In-hospital

Mortality: 47.3% 1 – Year

Mortality: 51.6%

317 Patients In-hospital

Mortality: 20.2% 1 – Year

Mortality: 22.7%

Car

diac

Ar

rest

(

)

259 Patients In-hospital

Mortality: 25.1% 1 – Year

Mortality: 33.6%

4157 Patients In-hospital

Mortality: 1.7% 1 – Year

Mortality: 5.5%

THOUGHTS ON SHOCK

•Not all shock is created equally

•What has held the field back is the lack of a common language– Lingua Franca

INTERMACS: FOUNDED 2009

• 1: Crash and Burn • 2: Sliding on Inotropes

• 3: Dependent Stability

• 4: NYHA 4

• 5: Exertion Intolerant

• 6: Exertion Limited

• 7: Advanced NYHA III

Stevenson et. Al. J Heart Lung Transplant 2009;28:535 41

SCAI AND HFSA: EXPERT CONSENSUS ON

CARDIOGENIC SHOCK CLASSIFICATION

David Baran (HFSA) Srihari Naidu (SCAI)

Steven Bailey (IC) William O’Neill (IC)

Daniel Burkhoff (Cardiol Res) Joseph Ornato (Emergency Med)

Cindy Grines (IC) Frank Pagani (CT Surgery)

Shelley Hall (AHF / Tx) Kelly Stelling (Shock Coord. Nursing)

Timothy Henry (IC) Holger Thiele (IC / Clin trials)

Steven Hollenberg (Critical Care)

Sean Van Diepen (Cardiol / Guidelines)

Navin Kapur (IC)

7

STAGE A: AT RISK

• A patient who is not currently experiencing signs or symptoms of CS but is at risk for its development.

• These patients may include those with NSTEMI, STEMI, acute or acute on chronic CHF

Physical Exam

Bioxchem Markers

Hemodynamics

“Not Sick” Normal Labs

Normotensive

Normal JVP Normal renal function

SBP ≥ 100 or normal for pt

Clear Lungs Normal lactic acid

If Swan in

Warm/ Well Perfused

CI ≥ 2.5

Strong distal pulses

CVP < 10

Normal mentation

PA Sat ≥ 65

STAGE B: BEGINNING CS

• A patient who has clinical evidence of relative hypotension or tachycardia without hypoperfusion

Physical Exam

Bioxchem Markers

Hemodynamics

“Not Sick” Elevated BNP

SBP <90 OR MAP<60 or >30 mm drop from baseline

Elevated JVP

Minimal renal dysfunction

Pulse ≥ 100 Normal Resp rate

Rales in Lung fields

Normal lactic acid

If Swan in

Warm/ Well Perfused

CI ≥ 2.2

Strong distal pulses

CVP < 10

Normal mentation

PA Sat ≥ 65

STAGE C: CLASSIC CS

• A patient with hypoperfusion that requires interventions such as inotrope,pressor or perc. MCS other than ECMO to restore perfusion

• These patients typically have relative hypotension

Physical Exam May Include any of:

Bioxchem Markers: May Include any of

Hemodynamics: May Include any of

“Sick”, Looks unwell, panicked

Lactate ≥ 2 SBP<90 or MAP < 60 or > 30 mm drop from baseline AND drugs/ device used to maintain BP above these

Ashen, mottled, dusky

Creatinine doubling or > 50 % loss of GFR

CI < 1.8 or < 2.2 on support

Extensive rales

Increased LFT’s

PCW < 15

BiPAP or

Increased

RA / CVP ≥

STAGE D: DOOM / DETERIORATING

• Patients similar to C but are getting worse

• They have failure to respond to initial interventions

Physical Exam May Include any of:

Bioxchem Markers: May Include any of

Hemodynamics: May Include any of

“Sick”, Looks unwell, panicked

Lactate ≥ 2 SBP<90 or MAP < 60 or > 30 mm drop from baseline

Ashen, mottled, dusky

Creatinine doubling or > 50 % loss of GFR

CI < 1.8 or < 2.2 on support

Extensive rales

Increased LFT’s

PCW < 15

BiPAP or mechanical vent

Increased BNP

Requiring multiple pressors or MCS to maintain perfusion

C O

STAGE E: EXTREMIS • Patient in cardiac arrest

with ongoing CPR or ECMO placement

• Being supported by multiple interventions

Physical Exam May Include any of:

Bioxchem Markers: May Include any of

Hemodynamics: May Include any of

“Trying to die”

Lactate ≥ 5 No blood pressure without CPR

Cardiac collapse

Arterial pH ≤ 7.2

PEA or refractory VT/VF

Mechanical Vent

Increased LFT’s

Hypotension despite max support

BiPAP or mechanical vent

Increased BNP

Defibrillated No time to draw

A IS FOR “ARREST”

• A– the Arrest modifier

• Any CPR however brief

SIMPLE EASY TO REMEMBER: THE INTERMACS OF SHOCK

PATH FORWARD

• Finalize the classification and publish

• Examine different populations to see if stages of CS correlate with mortality

• Drive recognition of CS and earlier transfers to centers with full complement of tools

• Hopefully improve outcomes by identifying MCS and ECMO options that are appropriately matched to level of illnesss

RECENT EXAMPLES OF CARDIOGENIC SHOCK TRIALS

• IAB SHOCK 2 Trial— • Systolic BP < 90 for more than 30 min, or needed

catecholamines to maintain systolic >90

• Signs of pulmonary congestion

• Impaired end organ perfusion • Altered mental status

• Cold clammy skin and extremities

• Oliguria (urine < 30/hr)

• Serum lactate > 2

IMPELLA CP IN AMI SHOCK

JACC, VOL . 6 9 , NO. 3 , 2 0 1 7

IMPRESS- IAB VS IMPELLA CP FOR SHOCK

• Multicenter, open label, randomized, N= 48

• IAB vs Impella CP, 1:1 randomization

• STEMI with immediate PCI

• CS as defined by SBP < 90 for 30 minutes or requirement for inotropes / pressors to maintain SBP > 90

• ALL Pts were VENTILATOR dependent to be enrolled!

• Informed consent WAIVED!

BASELINE

• Systolic BP 81-84 mm Hg

• 85-92 % had cardiac arrest

• Time to ROSC 21-27 minutes mean

• Lactate 7.5-8.9 mean

• pH 7.14-7.17

• 60 + % had LVEF < 40

• 71-79 % had therapeutic hypothermia

IMPRESS- IAB VS IMPELLA CP FOR SHOCK

Zeymer and Thiele. JACC Jan 2017. p 288-290

Circulation 2017

Early Transport to Cath Lab for ECMO and Revasc in Refractory VF (?OHCA)

Early Transport to Cath Lab for ECMO and Revascularization in

Refractory Ventricular Fibrillation

Out of Hospital

• VF/VT Initial rhythm • DCCV x3 and 300mg Amiodarone without ROSC • Time to CCL <30 min

Initial CCL

• ABG and lactate • Stop if: ETCO2<10mmHg, PaO2<50mmHg or Lactate >18

mmol/L • If ROSC, immediate Cor Angio +/- IABP. • If no ROSC, ECLS , then Cor Angio +/- IABP.

• Continue ACLS/ECLS for 90 minutes/PCI; if no ROSC by 90 minutes, declared dead