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