Primary Angioplasty and Hemodynamic Support in

Cardiogenic Shock

Department of Internal Medicine, College of Medicine, Yonsei University

Hyuck Moon Kwon, M.D.

Epidemiology of Cardiogenic Shock

Occurrence of shock

STEMI Non- STEMI

4.2-7.2%(GUSTO)

2.9%(PURSUIT)

Median time from enrollment to shock

9.6h 76h

Unstableangina

2.1%(PURSUIT)

94h

Hasdai et al. JACC 2000;36:687

Definition of Cardiogenic Shock

SBP < 90mmHg for >30min-1 hr that is :• Unresponsive to fluid administration alone• Secondary to cardiac dysfunction, or• signs of end-organ hypoperfusion, or • CI<2.2L/min/m and PCWP>15-18mmHg.

• SBP increase to>90mmHg within 1 hr after administration of inotrophic agents

• Death within 1 hr of hypotension but met other criteria for cardiogenic shock.

ACC clinical data standard JACC 2001;38:2127

ACC/AHA Guidelines (1999/2000) for PCIin Cardiogenic Shock

• Class I recommendation• Primary PTCA: within 36 hrs of an acute ST

elevation / Q-wave or new LBBB who develop cardiogenic shock are < 75 years old,

• Revascularization (PCI or CABG) within 18 hrs of onset of shock.

J Am Coll Cardiol 1999;34:`904

Predictors of Cardiogenic Shockafter STEMI

• Patient’s age - most important• SBP• HR• Killip Class

- Hasdai et al,Lancet 2000;356:749

Primary Angioplasty in CS

Employed criteria ? GUSTO-1 Selection bias ? SHOCK vs SMASH Randomized controlled study? Time of studies ?

Overall mortality: 44% Successful PCI: 33% Unsuccessful PCI: 81%

• Cardiogenic shock : 7.2% (among 41,021 pts)

• Overall 30-day mortality : 55%

• 30-day mortality of CABG group : 29%

• 30-day mortality of PTCA group : 22%

• Comparison of 1 yr mortality, PTCA vs no PTCA :

the hazard ratio : 0.81(95% CI,0.71-0.94; p<0.005)

•Limitations : not randomized study. Selection bias.

GUSTO-I (Cardiogenic shock subgroup analysis)

SHOCK trial : Randomized and controlled study

Acute Myocardial Infarction

Shock

Randomization

Emergency Revascularization Initial medical Stabilization

IABP/Pharmacological supportPossible prior thrombolysisEmergency earlyPTCA(60%)/CABG(40%)<= 6 hrs

IABP/Pharmacological supportThrombolysis unless absoluteContraindication (63%)Delayed revasc.(25%) >54hr

<= 36hr

<= 12hr

Hochman et al,NEJM 1999;341:625

• Primary end point : 30-day mortality• Secondary end point : 6 mo. mortality

Outcome and Subgroup

30-day mortalityTotalAge<75yrAge>=75yr6-mo. mortalityTotalAge<75yrAge>=75yr

ERV

46.7(152) 41.4(128) 75.0(24)

50.3(151) 44.9(127) 79.2(24)

Medical Therapy

56.0(150)56.8(118)53.1(32)

63.1(149)65.0(117)56.3(32)

Difference

-9.3 -15.4 +21.9

-12.8 -20.1 +22.9

percent(number in subgroup)

Relative risk

0.83 0.73 1.41

0.80 0.70 1.41

P-value

0.110.01

0.0270.003

SHOCK Trial : Mortality among Study Patients

Hochman et al ,NEJM 1999;341:625

PCI in the SHOCK Trial Registry (93-97’, n=884)

Webb J et al, Am. Heart J.2001;141:964-71

In-hospital mortality: 46.4% in PCI (n=276) vs 78.0% in medically (n=499) MI-PCI: Median 8.8hrs, Shock-PCI: 3.3hrs

PCI within 6 hrs of MI 40.2%PCI within 6-12 hrs of MI 50.9%PCI within 12-24 hrs of MI 60.5%PCI within 24hrs of MI 43.9%

Pts with PCI: younger, shock earlier, higher LVEF & CI

Final TIMI flow grade after PCI and in-hospital mortality rates in SHOCK Registry patients with pump(Lt.or Rt.ventricular) failure. (P< 0.001).

( Webb J et al, Am. Heart J.2001;141:964-71)

0

20

40

60

80

100

0 or 1(n=35) 3(n=111)

85.7%

50.0%

In-h

ospi

tal m

orta

lity

(%)

33.3%

2(n=24)Final TIMI Flow Grade

Angiographic success and in-hospital mortality rates in SHOCK Registry patients with pump failure. Success is defined as residual stenosis<50% and final TIMI flow grade of 2 or 3(P< 0.001).

( Webb J et al, Am. Heart J.2001;141:964-71)

0

20

40

60

80

100

Unsuccessful(n=40) Successful(n=119)

82.5%

36.1%

In-h

ospi

tal m

orta

lity

(%)

Region

ANCEuropeABUSAP value

Hospital mortality(%)

58 65 79 39 < 0.0001

ERV(%)

25 31 46 57 <0.0001

Stent use

25 80 53 80 0.0019

GPIIbIIIa Inhibitor 5 15 9 26 0.0005

Global Use of Revascularization for Pts. in Cardiogenic Shock: Global registry of Acute Coronary Events (GRACE, 99-00’, n=535)

ANC: Australia/New Zealand/Canada, AB: Argentina/brazil

Dauerman et al, Am J cardiol 2001;88(suppl 5A)

•The most powerful predictor of in–hospital survival : PCI with stenting(n=535, odds ratio, 5.8 ; 95% confidence interval, 3.3-10.4)

Long-term Results after acute PCI in AMI with shock

12-months survival rate 47% SHOCK trial

60% Ajani et al. AJC 2001;87:633

80% Ammann et al. Int J of cardiology 2002;82:127

Early prediction - ERV with stenting & anti-PLT !!

Beneficial effect of GP IIb/IIIa receptor blockers in patients undergoing primary PCI/Stenting in CS:

1-month mortality (n=74) 19 vs 41%Antoniucci D et al. Am J Cardiol. 2001;88:5A

In hospital mortality (n=323) 26.4 vs 34.4%Moscucci M et al. JACC. 2002;39:330A

Glycoprotein IIb/IIIa inhibitors

Hemodynamic Support in Cardiogenic Shock

IABP in Cardiogenic Shock

• Diastolic inflation - Augmentation of DBP

• Systolic Deflation - Afterload Reduction

• Contraindicated in severe Aortic regurgitation !

-Increases diastolic coronary arterial perfusion

- Reduce LV wall stress- Decrease myocardial oxygen demand- Increase in cardiac output

• IABP as an an adjunctive treatment to revascularization in GUSTO-I trial, a trend towards lower 30-day and 1 -year mortality rates. (Anderson et al. JACC 1997;30:708-715)

(Barron et al,Am heart J 2001;141:933-939)

IABP in Cardiogenic Shock complicating AMI

• SHOCK trial : IABP used in 86%• National Registry of MI-2 IABP in 7268/23180 (31%): Thrombolytic therapy with IABP :49 vs 67 % Primary angioplasty with IABP :47 vs 45 %

Conclusion

• Prevention is the best policy: identification of pre-shock state followed by preventing deterioration into cardiogenic shock.

• Strategy of ERV: PTCA/CABG accompanied with IABP support. for > 75yrs old,invasive strategy on case by case basis.

• TIMI flow after PCI was strongly associated with in-hospital mortality rate.

Thrombolytic therapy

• The outcome of cardiogenic shock is closely linked to the patency of the culprit coronary arteries

• Thrombolytic therapy has decreased the occurrence of shock among patients with persistent STEMI.

• The GUSTO-I : t-PA is more efficacious than streptokinase in preventing shock.

Thrombolysis in cardiogenic shock

• Results have been disappointing• Cause : ? limited efficacy of lytics in the

setting of low perfusion pressure.• GISSI-I Study

Mortality of thrombolysis(streptokinase) group = 69.9% Mortality of. control group = 70.1%

-David Hasdai et al,Lancet 2000;356:753