cardiogenic shock kasia hryniewicz, m.d. minneapolis heart institute, abbott northwestern hospital,...
TRANSCRIPT
![Page 1: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/1.jpg)
Cardiogenic shock
Kasia Hryniewicz, M.D.
Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
Greater Twin Cities Area Chapter of AACN Fall Symposium
November 8, 2013
![Page 2: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/2.jpg)
Definition
• Cardiogenic shock (CS) is a clinical condition of inadequate tissue perfusion due to cardiac dysfunction.
![Page 3: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/3.jpg)
Definition cont
• persistent hypotension (systolic blood pressure <80 to 90 mmHg or mean arterial pressure 30 mmHg lower than baseline)
• severe reduction in cardiac index
(<1.8 L/ min per m2 without support or <2.0 to 2.2 L/ min per m2 with support)• adequate or elevated filling pressures
![Page 4: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/4.jpg)
Etiology
Cardiogenic shock
Acute Chronic- End stage
cardiomyopathy, inotrope dependent
![Page 5: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/5.jpg)
Etiology – Acute CS
1. Acute myocardial infarction– Large infarct, reinfarction– Mechanical complications MR, VSD, free wall
rupture– Right ventricular infarction
2. Non-infarct related- acute myocarditis- acute MR – chordal rupture/endcarditis- acute AI – dissection, endocarditis- stress induced cardiomyopathy- myocardial contusion
![Page 6: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/6.jpg)
Incidence- SHOCK registry
• 1190 pts- overall incidence – 5%
• The majority of patients have a STEMI, but CS occurs in 2.5% (NSTEMI)
LV failure 79%
Severe MR 7%
VSD 4%
Isolated RV infarct
2%
Tamponade 1.4%
Other 7%
![Page 7: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/7.jpg)
Shock - pathophysiology
Hochman J:Circulation 107:2998, 2003
![Page 8: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/8.jpg)
Risk factors
• Older age• Anterior MI• Hypertension• diabetes mellitus• multivessel coronary artery disease• Prior MI or diagnosis of heart failure• STEMI• Left bundle branch block on the
electrocardiogram (ECG)
![Page 9: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/9.jpg)
Risk factors continue
• In the GUSTO-I and GUSTO-III trials of fibrinolytic therapy in acute STEMI
- Age- systolic blood pressure- heart rate- Killip classwere major predictors of CS accounting
for over 95 percent of the predictive information.
![Page 10: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/10.jpg)
Killip acute HF class
Class 1 Absence of rales over the lung fields and absence of S3.
Class 2 Rales over 50% or less of the lung fields or the presence of an S3.
Class 3 Rales over more than 50% of the lung fields.
Class 4 Cardiogenic shock
![Page 11: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/11.jpg)
Symptoms
• severe systemic hypotension• signs of systemic hypoperfusion (eg, cool
extremities, oliguria, and/or alteration in mental status)
• respiratory distress due to pulmonary congestion.
Not all patients present with this syndrome. In
particular, most patients develop shock after presentation.
![Page 12: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/12.jpg)
OnsetBased on GUSTO trials• Shock was present on admission in 0.8 % at hospital
presentation and an additional 5.3 % developed shock after admission, either as a sudden event or as a gradual fall in blood pressure.
• Approximately 50 percent of patients who developed shock after admission did so within the first 24 hours after the infarct.
In SHOCK trial: the median time from MI to onset of cardiogenic shock was 5.5 hours and 75 % of patients developed shock within 24 hours.
![Page 13: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/13.jpg)
Onset cont
• Shock developed significantly later among patients with a NSTEMI (median 76 to 94 hours versus 9.6 hours for those with STEMI).
![Page 14: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/14.jpg)
Pre-shock
COMMIT trial randomization to early beta blockade was associated with a 30% higher occurrence of CS in patients:
- > 70 years of age- SBP < 120 mm Hg- HR >110 beats per minute- Killip Class > 1
Commit trial.
![Page 15: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/15.jpg)
Diagnosis is key!
• H&P• ECG• Echo (TTE/TEE)• S-G catheter• Coronary angiogram
![Page 16: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/16.jpg)
Treatment
![Page 17: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/17.jpg)
![Page 18: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/18.jpg)
Shock trial
• Inclusion criterion: shock due to LV failure complicating myocardial infarction
• 302 pts randomly assigned to emergency revascularization (n=152) or initial medical stabilization (n=150).
![Page 19: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/19.jpg)
Shock trial
• IABP was performed in 86 percent of the patients in both groups.
• The primary end point mortality from all causes at 30 days.
• Secondary end point six-month survival
![Page 20: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/20.jpg)
Shock trial results
- No difference in mortality at 30 days (46.7% vs 56%, p=0.11)
- Significant decrease in all cause mortality at 6 months (50.3% vs. 63.1% p=0.027).
![Page 21: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/21.jpg)
Shock trial – what have we learned?
1. Average LV ejection fraction (EF) is only moderately severely depressed (30%), with a wide range of EFs and LV sizes noted.
2. SVR on vasopressors is not elevated
3. A clinically evident systemic inflammatory
response syndrome is often present in patients with CS.
4. Most survivors have NYHA class I status.
![Page 22: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/22.jpg)
Predictors of outcome• Coronary anatomy - Higher mortality in pts with a LM
SVG lesion than in those with LCX, LAD or RCA (79 and 70 % vs 37and 42%). RCA culprit lesions were associated with the best prognosis
• Echocardiographic predictors - (LVEF) and severity of mitral regurgitation (MR). LVEF <28 percent survival at one year was
24% vs 56% Moderate or severe MR survival at one year was 31 % vs 58% However, there was benefit of early revascularization at all levels of LVEF and MR grade.
• Symptom onset to reperfusion time - mortality only 6.2 percent in patients reperfused within two hours of symptom onset
![Page 23: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/23.jpg)
![Page 24: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/24.jpg)
Methods• Randomized, prospective, open-label,
multicenter trial• 600 patients with CS complicating acute
myocardial infarction, randomly assigned to
- IABP, (301 pts) or
- no IABP (299 pts)
plus early revascularization• The primary end point 30-day all-cause
mortality. • Safety assessments - major bleeding,
peripheral ischemic complications, sepsis, and stroke.
![Page 25: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/25.jpg)
Results
![Page 26: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/26.jpg)
Results
![Page 27: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/27.jpg)
Results
• At 30 days –
119 patients in the IABP group (39.7%)
and
123 patients in the control group (41.3%)
had died (P = 0.69).
- At 6 months – no difference in mortality.
![Page 28: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/28.jpg)
Conclusions…
• The use of IABP did not significantly reduce 30-day or 6 month mortality in patients with cardiogenic shock complicating acute MI for whom an early revascularization strategy was planned.
![Page 29: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/29.jpg)
Conclusions…
The IABP-SHOCK II trial could have affirmed contemporary clinical practice and guidelines,“
"Instead, it revealed surprising results. . . . We must now move forward with the understanding that a cardiovascular condition with 40% mortality at 30 days remains unacceptable
![Page 30: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/30.jpg)
CS-Management
• General measures- ventilation support to correct hypoxemia
and, in part, acidosis- Optimize intravascular volume- Sodium bicarbonate only for severe
metabolic acidosis (arterial pH less than 7.10 to 7.15)
- Aspirin- Intravenous heparin- insertion of pulmonary artery catheter
![Page 31: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/31.jpg)
Management cont
Pharmacologic support- Vasopressors and inotropes
(norepinephrine, vasopressin, dopamine, neosinephrine, dobutamine, milrinone)
Mechanical support- IABP???- Full mechanical support (ECMO?)
![Page 32: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/32.jpg)
Which pressor is best?
![Page 33: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/33.jpg)
Results
• 1679 pts, 858 dopamine and 821 norepinephrine.
• Primary outcome – rate of death at 28 days
• Secondary endpoint – number of days without need for organ support and occurrence of adverse events.
![Page 34: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/34.jpg)
Results
1. No difference in primary outcome
(52.5% vs 48.5%)
2. Less AE in norepinephrine group
(24.1% vs 12.4%, p<0.001)
3. In CS subgroup analysis
Dopamine was associated with significantly higher mortality comparing with norepinephrine.
![Page 35: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/35.jpg)
What about mechanical support?
![Page 36: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/36.jpg)
ExtraCorporeal Membrane Oxygenation
• VV (veno-venous) respiratory failure• VA (veno-arterial) full hemodynamic
support for refractory cardiogenic shock
• Relatively easy placement• Temporary stabilization, bridge to
recovery/permanent VAD• Requires anticoagulation
![Page 37: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/37.jpg)
![Page 38: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/38.jpg)
ECMO at ANWH
• 46 pts between 2012-2013• Percutanously placed in the cath lab• Survival to discharge 70%• Major complications – bleeding • Patients managed by HF
cardiologists/RNs/perfusionists in CT ICU
![Page 39: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/39.jpg)
Approach to a pt with CS
Acute MIMechanical complications
Surgery
H&P, ECG, echo (TEE)
Cath lab
Revascularization
IABP?/MCS (ECMO)?
Severely depressed EF, STE
PCIMCS (ECMO?)
![Page 40: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/40.jpg)
Thank you!
![Page 41: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/41.jpg)
![Page 42: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/42.jpg)
![Page 43: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/43.jpg)
![Page 44: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/44.jpg)
![Page 45: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/45.jpg)
![Page 46: Cardiogenic shock Kasia Hryniewicz, M.D. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN Greater Twin Cities Area Chapter of](https://reader035.vdocuments.net/reader035/viewer/2022081504/56649e4c5503460f94b40e8c/html5/thumbnails/46.jpg)