evolving algorithms for the treatment of acute mi
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Evolving Algorithms for the Treatment of Acute MI Complicated by Cardiogenic Shock
Advances in Heart DiseaseDecember 8, 2019
Krishan Soni, MD, MBAAssistant Clinical ProfessorDivision of CardiologyUCSF School of Medicine
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Disclosures
No Conflicts of InterestNo Financial Disclosures
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Learning Objectives
§ Appreciate the incidence, etiologies, and outcomes associated with cardiogenic shock (CS)
§ Gain familiarity with a modern classification for cardiogenic shock
§ Understand data driven interventions and guidelines for managing patients with acute myocardial infarction (AMI) complicated by cardiogenic shock
§ Recognize how multidisciplinary team-based approaches may improve outcomes for patients with cardiogenic shock
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§ Major Society Statements and Guidelines 2017-2019
§ Clinical Trials Published 2012-2019
Latest Relevant Information
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Outline
§ Definition of shock and the shock spiral
§ A novel classification of shock (SCAI)
§ Interventions to treat AMI complicated by cardiogenic shock- Revascularization - Mechanical support therapies
§ Multidisciplinary team based approaches- National Cardiogenic Shock Initiative (NCSI)- Inova Shock Team
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Outline
§ Definition of shock and the shock spiral
§ A novel classification of shock (SCAI)
§ Interventions to treat AMI complicated by cardiogenic shock- Revascularization - Mechanical support therapies
§ Multidisciplinary team based approaches- National Cardiogenic Shock Initiative (NCSI)- Inova Shock Team
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Traditional Definition of Cardiogenic Shock
“A state in which ineffective cardiac output (CO) due to a primary cardiac dysfunction results in inadequate end-organ
perfusion.”
Physical Exam Biomarkers Hemodynamics
Diagnosis made by
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Hemodynamic Phenotypes
Van Diepen, S, et al. Contemporary Management of Cardiogenic Shock. Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525
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The Shock Spiral
Van Diepen, S, et al. Contemporary Management of Cardiogenic Shock. Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525
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Causes of Cardiogenic Shock
Jones TL, Nakamura K, McCabe JM. Cardiogenic shock: evolving definitions and future directions in management. Open Heart 2019;6:e000960. doi:10.1136/openhrt-2018-000960
60-80%
Incidence of CS complicating AMI is
~ 6.5% to 10.1%
Cardiogenic Shock
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Incidence of Cardiogenic Shock Increasing
Mandawat, A, et al. Circ Cardiovasc Interv. 2017;10:e004337. DOI: 10.1161/CIRCINTERVENTIONS.116.004337.
And in hospital mortality remains high
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Outline
§ Definition of shock and the shock spiral
§ A novel classification of shock (SCAI)
§ Interventions to treat AMI complicated by cardiogenic shock- Revascularization - Mechanical support therapies
§ Multidisciplinary team based approaches- National Cardiogenic Shock Initiative (NCSI)- Inova Shock Team
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No standard for defining cardiogenic shock
Thiele, H, et Al. Management of cardiogenic shock complicating myocardial infarction: an update 2019. European Heart Journal (2019) 40, 2671–2683.
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SCAI Clinical Expert Consensus Statement Classification of Cardiogenic Shock
Society for Coronary Angiography and Intervention (SCAI)
Catheter Cardiovasc Interv. 2019; 1–9. https://doi.org/10.1002/ccd.28329
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Classification of Cardiogenic Shock
Baran, DA, Grines, CL, Bailey, S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Catheter Cardiovasc Interv. 2019; 1–9. https://doi.org/10.1002/ccd.28329
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Classification of Cardiogenic Shock
Baran, DA, Grines, CL, Bailey, S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Catheter Cardiovasc Interv. 2019; 1–9. https://doi.org/10.1002/ccd.28329
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Shock Stage Predictive of Mortality
Jentzer, JC, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit. JACC 2019. Vol 73, 17, 2117-2128
Mayo Clinic All CICU patients in shock 2007-2015
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Higher stages predict mortality regardless of shock etiology
Jentzer, JC, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit. JACC 2019. Vol 73, 17, 2117-2128
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Outline
§ Definition of shock and the shock spiral
§ A novel classification of shock (SCAI)
§ Interventions to treat AMI complicated by cardiogenic shock- Revascularization - Mechanical support therapies
§ Multidisciplinary team based approaches- National Cardiogenic Shock Initiative (NCSI)- Inova Shock Team
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Potential Shock Care Pathway
Van Diepen, S, et al. Contemporary Management of Cardiogenic Shock. Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525
“Despite improving survival in recent years, patient morbidity
and mortality remain high, and there are few evidence-based
therapeutic interventions known to clearly improve patient
outcomes”
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Three interventions well studied…Culprit Lesion
RevascularizationMulti-vessel
RevascularizationIntra-aortic Balloon
Pump (IABP)
1999: SHOCK 2017: CULPRIT-SHOCK 2012: IABP-SHOCK II
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SHOCK Trial (1999)Question: Does culprit vessel revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock?
Hochman, JS e tal. N Engl J Med 1999;341:625-34.
§ 300 patients with shock due to LV failure complicating MI
§ Randomly assigned to:- Emergency revascularization
(CABG or angioplasty) - Initial medical stabilization
§ Primary end point: Mortality from all causes at 30 days.
§ Secondary end point: Six-month survival.
No significant difference
Culprit LesionRevascularization
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SHOCK Trial (1999)Question: Does culprit vessel revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock?
Hochman, JS e tal. N Engl J Med 1999;341:625-34.
§ Non-significant difference in mortality at 30 days: - 46.7% (revascularization)- 56% (medical therapy); - Difference: 9.3%, p=0.11
§ Significant difference in mortality at 6 months:- 50.3% (revascularization) - 63.1% (medical therapy); - Difference: 12.8%, p=0.027
Establishes culprit vessel
revascularization as a standard
strategy in managing AMI and cardiogenic shock
Culprit LesionRevascularization
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CULPRIT-SHOCK (2017)Question: Does non culprit artery revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock?
Thiele, H et al. NEJM (2018). DOI: 10.1056/NEJMoa1808788
§ 706 patients with AMI, multi-vessel disease and shock
§ Randomly assigned to:- Culprit lesion only PCI- Immediate multi-vessel PCI
§ Primary end point: death or renal-replacement therapy at 30 days
§ Secondary end point: one year death from any cause, recurrent MI, repeat revascularization, re-hospitalization for CHF
Multi-vessel Revascularization
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CULPRIT-SHOCK (2017)
§ Multi-vessel PCI group had higher death and renal failure at 30 days: - 45.9% (culprit only group)- 55.4% (multi vessel) p=0.01
§ At one year: - Death did not differ:
§ 50.0% (culprit only group) vs 56.9% (multi vessel) § RR=0.88 [CI 0.76-1.01]
- Repeat revascularization higher for culprit only group§ 32.3% vs 9.4% § RR 3.44 [2.39-4.35]
Results in guideline changes to support
infarct related vessel PCI only
Question: Does non culprit artery revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock?
Thiele, H et al. NEJM (2018). DOI: 10.1056/NEJMoa1808788
Multi-vessel Revascularization
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IABP SHOCK II (2012)
§ Before 2012: Intra aortic balloon counter pulsation (IABP) was a class I treatment for cardiogenic shock complicating acute MI
§ Evidence was based mainly on registry data
Thiele, H et al. N Engl J Med 2012.DOI: 10.1056/NEJMoa1208410
§ Randomized prospective trial§ 600 patients with CS and AMI§ All expected receive medical
therapy and early revascularization
§ Randomized to IABP or no IABP
Intra-aortic Balloon Pump (IABP)
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Thiele, H et al. N Engl J Med 2012.DOI: 10.1056/NEJMoa1208410
Primary Outcome: Death at 30 days§ IABP group (39.7%) § Control group (41.3%) § RR 0.96, P = 0.69
No significant differences:§ Time to hemodynamic
stabilization§ Length of stay in ICU§ Serum lactate levels§ Renal function
IABP SHOCK II (2012) Intra-aortic Balloon Pump (IABP)
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Three interventions well studied…Culprit lesion
RevascularizationMulti-vessel
RevascularizationIntra-aortic Balloon
Pump (IABP)
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Percutaneous Assist Device Options
Thiele, H, et Al. Management of cardiogenic shock complicating myocardial infarction: an update 2019. European Heart Journal (2019) 40, 2671–2683.
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Percutaneous Assist Devices: Flow
Atkinson, TM, et al. A Practical Approach to Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention. JACC: Cardiovascular Interventions 2016 (9), 9: 871- 883
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Percutaneous Assist Devices: Hemodynamics
Atkinson, TM, et al. A Practical Approach to Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention. JACC: Cardiovascular Interventions 2016 (9), 9: 871- 883
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Percutaneous Assist Devices: Complications
Atkinson, TM, et al. A Practical Approach to Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention. JACC: Cardiovascular Interventions 2016 (9), 9: 871- 883
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• 287 consecutive unselected patients presented with AMICS and underwent PCI• Enrolled in the catheter-based ventricular assist device registry (cVAD)• Survival to discharge was 44%.
• Early implantation of a MCS device before PCI, and before requiring inotropes / vasopressors was associated with increased survival.
Basir, M, et al. Am J Cardiol 2016. http://dx.doi.org/10.1016/j.amjcard.2016.11.037
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Survival improved with earlier implantation of MCS therapy and reduction in use of inotropes
Basir, M, et al. Am J Cardiol2016. http://dx.doi.org/10.1016/j.amjcard.2016.11.037
cVAD Registry: Improved survival with MCS
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Percutaneous Assist Devices: Stop the Spiral
Jones TL, Nakamura K, McCabe JM. Cardiogenic shock: evolving definitions and future directions in management. Open Heart 2019;6:e000960. doi:10.1136/openhrt-2018-000960
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Guideline Directed Management
2018 ESC/EACTS Guidelines on myocardial Revascularization. European Heart Journal (2019) 40, 87–165
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Guideline Directed Management - DO
2018 ESC/EACTS Guidelines on myocardial Revascularization. European Heart Journal (2019) 40, 87–165
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Guideline Directed Management – MAYBE DO
2018 ESC/EACTS Guidelines on myocardial Revascularization. European Heart Journal (2019) 40, 87–165
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Guideline Directed Management – DON’T DO
2018 ESC/EACTS Guidelines on myocardial Revascularization. European Heart Journal (2019) 40, 87–165
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Outline
§ Definition of shock and the shock spiral
§ A novel classification of shock (SCAI)
§ Interventions to treat AMI complicated by cardiogenic shock- Revascularization - Mechanical support therapies
§ Multidisciplinary team based approaches- National Cardiogenic Shock Initiative (NCSI)- Inova Heart Team
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Detroit Cardiogenic Shock Initiative (CSI)
O’Neil, W. A National Cardiogenic Shock Initiative (CSD). Slide Presentation. TCT 2017.
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Detroit CSI Protocol
O’Neil, W. A National Cardiogenic Shock Initiative (CSD). Slide Presentation. TCT 2017.
GOALS§ Rapidly identify patients with
cardiogenic shock§ Measure hemodynamics pre PCI§ Use early mechanical support if LVEDP
> 15 or cardiac index < 2.2§ Revascularization§ Measure
- Cardiac Power Output (CPO) - Pulmonary Artery Pulsitility Index (PAPI)
§ Wean or augment support based on CPO/PAPI
§ Minimize Pressors/Inotropes
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Detroit CSI Protocol
O’Neil, W. A National Cardiogenic Shock Initiative (CSD). Slide Presentation. TCT 2017.
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Detroit CSI Protocol
O’Neil, W. A National Cardiogenic Shock Initiative (CSD). Slide Presentation. TCT 2017.
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Detroit CSI Protocol
O’Neil, W. A National Cardiogenic Shock Initiative (CSD). Slide Presentation. TCT 2017.
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Detroit CSI Protocol
O’Neil, W. A National Cardiogenic Shock Initiative (CSD). Slide Presentation. TCT 2017.
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Detroit CSI Protocol: Results
O’Neil, W. A National Cardiogenic Shock Initiative (CSD). Slide Presentation. TCT 2017.
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National Cardiogenic Shock Initiative (NCSI)
O’Neil, W. Acute Cardiogenic Shock: The Number One Unresolved Challenge in Cardiovascular Disease. Slide Presentation. TCT 2910
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National Cardiogenic Shock Initiative (NCSI)
O’Neil, W. Acute Cardiogenic Shock: The Number One Unresolved Challenge in Cardiovascular Disease. Slide Presentation. TCT 2910
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National Cardiogenic Shock Initiative (NCSI)
O’Neil, W. Acute Cardiogenic Shock: The Number One Unresolved Challenge in Cardiovascular Disease. Slide Presentation. TCT 2910
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National Cardiogenic Shock Initiative (NCSI)
O’Neil, W. Acute Cardiogenic Shock: The Number One Unresolved Challenge in Cardiovascular Disease. Slide Presentation. TCT 2910
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National Cardiogenic Shock Initiative (NCSI)
O’Neil, W. Acute Cardiogenic Shock: The Number One Unresolved Challenge in Cardiovascular Disease. Slide Presentation. TCT 2910
Lower CPO and higher inotrope requirement are associated with poor prognosis
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National Cardiogenic Shock Initiative (NCSI)
Bashir M, et al. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv. 2019;93:1173–1183.
Predictors of Mortality§ Age > 70 OR 2.41§ Lactate >4 OR 6.90§ CPO < 0.6 OR 3.79§ Creatinine >2 OR 3.75
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Mortality Rates in Shock over Time
Bashir M, et al. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv. 2019;93:1173–1183.
Pre PCI Post PCI MCSShock Team
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Shock team at Inova Heart and Vascular
Tehrani B, et al. Standardized Team-Based Care for Cardiogenic Shock. JACC 2019 (73) 13. https://doi.org/10.1016/j.jacc.2018.12.084
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Shock team at Inova Heart and Vascular
Tehrani B, et al. Standardized Team-Based Care for Cardiogenic Shock. JACC 2019 (73) 13. https://doi.org/10.1016/j.jacc.2018.12.084
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Shock team at Inova Heart and Vascular
Tehrani B, et al. Standardized Team-Based Care for Cardiogenic Shock. JACC 2019 (73) 13. https://doi.org/10.1016/j.jacc.2018.12.084
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Take Home Points
§ Cardiogenic shock is a spiral that involves an acute insult, poor cardiac function, and worsening end organ perfusion resulting in multi organ failure and death.
§ The 5 stages of shock are associated with increasing mortality and can be used to quickly risk stratify patients.
§ Guidelines support culprit vessel PCI in patients with acute myocardial infarction (AMI) and cardiogenic shock (CS). Multivessel PCI and use of IABP are no longer supported.
§ Multidisciplinary shock teams and the use of hemodynamics (and CPO) to inform use of MCS and reduce use of inotropes may result in lower mortality in cardiogenic shock.
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Temporal Trends in Mortality
Wayangankar et al. Trends in Post-ACS Cardiogenic Shock Patients. JACC Cardiovascular Interventions. 2 0 1 6 . Vol 9, 4, 3 4 1 – 5 1.
Patients with AMI and CS who are brought to the cath lab for PCI
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IMPRESS Trial (2017)
Ouweneel, D.M. et al. J Am Coll Cardiol. 2017;69(3):278–87.
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Cardiac Power
Jones TL, Nakamura K, McCabe JM. Cardiogenic shock: evolving definitions and future directions in management. Open Heart 2019;6:e000960. doi:10.1136/openhrt-2018-000960
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Percutaneous Assist Devices: An Algorithm
Atkinson, TM, et al. A Practical Approach to Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention. JACC: Cardiovascular Interventions 2016 (9), 9: 871- 883
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Potential Shock Care Pathway
Van Diepen, S, et al. Contemporary Management of Cardiogenic Shock. Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525
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