Cardiogenic Shock: A 55 year old with no known medical problems - PDF document

12/17/16 Case Cardiogenic Shock: • A 55 year old with no known medical problems presents with an anterior STEMI 5 days after the start of symptoms. Pharmacological and • Despite prompt revascularization and vasopressor support hypotension persists and Mechanical Therapy • An IABP is inserted with temporary improvement in hemodynamics. Christopher Barnett MD, MPH • An echocardiogram demonstrates a ventricular septal defect and he is taken urgently to the operating room for repair. Director, Medical Cardiovascular Intensive Care Unit • Post operatively hemodynamics deteriorate and he is placed Director, Pulmonary Hypertension Program on ECMO. Medstar Heart and Vascular Institute • Seven days later he is weaned off ECMO and decanulated. Medstar Washington Hospital Center • He is subsequently discharged home from the hospital. Washington, DC Shock is Inadequate End Organ Perfusion Differential Diagnosis of Cardiogenic Shock in Patients in the CVICU Despite Adequate Fluid Resuscitation • Complications of acute myocardial infarction • Left ventricular dysfunction (80% of cardiogenic shock) • VSD • Criteria for the diagnosis of cardiogenic shock • Ventricular wall rupture • Acute valvular heart disease • SBP <90 for >30 minutes or vasopressor needed to • Decompensated chronic HFrEF maintain SBP >90 • HFpEF • Pulmonary congestion/elevated LV filling pressures • Viral cardiomyopathy • Signs of impaired perfusion • Post cardiotomy • Mental status • Arrhythmia • Cool extremities • Valvular heart disease • Oliguria • Right ventricular failure • Elevated lactate • Post operative right ventricular failure • Decompensated chronic pulmonary hypertension 1

12/17/16 Don’t Forget About Non- Mortality in Cardiogenic Shock Is High Cardiogenic Causes of Shock! • Distributive • Secondary to acute MI Factors associated with 22-88% increased mortality after • Sepsis acute MI: • Ventricular septal • Obstructive rupture 87% • Advanced age • Pulmonary embolism • Shock on admission • Neurogenic • Clinical end organ hypoperfusion • Spinal chord injury • Right ventricular failure • Anoxic brain injury • Hypovolemic • Decreasing SBP from PAH 30-48% • Acute blood loss • Prior CABG • Intravascular volume depletion • Non-inferior AMI • Creatinine >1.9 Machuca. Circulation, 2015. Reyentovich. Nat Reviews Cardiology, 2016. Approach to Patients With Initial Cardiac Dysfunction Leads To A Suspected Cardiogenic Shock Cascade of Downstream Abnormalities • Optimize volume status • Use vasopressors to maintain adequate blood pressure to prevent end organ ischemia and dysfunction • Use Inotropes (inodilators) to optimize cardiac output • Continually reevaluate response to therapy • Consider surgical repair of structural heart disease early • Consider implementation of mechanical support early Reyentovich. Nat CV Reviews, 2016. 2

12/17/16 Survival Is Improved With Early It Is Unknown If Culprit PCI Is Revascularization in SHOCK From ACS Superior to Multivessel PCI In Shock Hochman. JAMA, 2006. http://www.culprit-shock.eu/the-project/ Hochman. NEJM, 1999. The Pulmonary Artery Catheter Is Useful Alpha Agonists: Mechanism of Action Carefully Selected Patients With Cardiogenic Shock • Escape trial • Found not difference in outcomes between therapy guided with PAC or without • Excluded Dobutamine or dopamine >3 mcg/kg/min, any milrinone, Cr>3.5 Binanay. JAMA, 2005. Overgaard. Circulation, 2008. Chaterjee. Circulation, 2009. 3

12/17/16 Mechanism of Action: Beta Agonists Mechanism of PDE- Inhibitor: Milrinone Vascular smooth muscle Cardiac myocyte Overgaard. Circulation, 2008. Overgaard. Circulation, 2008. Catecholaminergic Receptor Vasopressors In Cardiogenic Activity Shock: What Choice Is Best? • Shock trial: Increased Drug α β1 β2 D death with dopamine Dopamine +++ (3+) ++++ (4+) ++ (2+) +++++ (5+) Death at 28 days in cardiogenic shock Dobutamine + (1+) +++++ (5+) +++ (3+) NA Norepinepherine +++++ (5+) +++ (3+) ++ (2+) NA • Post hoc subset Epinepherine +++++ (5+) ++++ (4+) +++ (3+) NA analysis of 280 patients Isoproterenol 0 +++++ (5+) +++++ (5+) NA • Pressor choice requires Phenylepherine +++++ (5+) 0 0 NA careful consideration of individual patient hemodynamics to choose the optimal vasopressor Overgaard. Circulation, 2008. De Backer. NEJM, 2010. . 4

12/17/16 Hemodynamic Benefits From IABP Varies By Mechanisms and Hemodynamic Population Studied Effects of IABP • Increased diastolic • ↓SBP blood flow to the • ↑ DBP proximal aorta • ↑ MAP • Reduced afterload due • ↓ HR to vacuum effect of balloon deflation • ↓ PCWP • ↑ CO • ↑ Coronary perfusion Prodzinsky. Shock, 2012. Hemodynamic Benefits From IABP Routine Use Of An IABP After AMI Varies By Population Studied Does Not Improve Outcomes • 598 patients with hypotension pulmonary edema and impaired end organ perfusion • No difference in mortality • Trend towards benefit in younger patients without prior MI and anterior MI Stone. JACC, 2003. Theile. NEJM, 2012. 5

12/17/16 Current Percutaneous Mechanical Support Options Theile. Eur Heart J, 2015. O’Gara. JACC, 2013. Patient Factors To Be Considered Characteristics of Temporary Mechanical In Mechanical Support Support Devices • Irreversible neurological damage • Intracranial bleeding or other condition that precludes anticoagulation • Inaccessible vessels for cannulation • Irreversible cardiopulmonary failure in patients who are no candidates for transplantation • Multiorgan dysfunction • Malignant disease with <5 year life expectancy • Potential for rehabilitation and quality of life after recovery Machuca. Circulation, 2015. Reyentovich. Nat Reviews Cardiology, 2016. 6

12/17/16 Impella Device Impella Registry: Early Implantation Impella Registry: Early Implantation of Impella May Improve Outcomes of Impella May Improve Outcomes O’Neill. J Int Cardiology, 2014. O’Neill. J Int Cardiology, 2014. 7

12/17/16 IMPRESS trial of Impella Compared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis Demonstrates Better Meta Analysis Demonstrates Better Hemodynamics, Increased Complications, Hemodynamics, Increased Similar Outcomes Complications, Similar Outcomes Cheng. Eur Heart J, 2009. Cheng. Eur Heart J, 2009. 8

12/17/16 The Use Of MCS Devices Has Few Data To Evaluate ECMO Increased Dramatically Machuca. Circulation, 2015. Stretch. JACC, 2014. Shift To Earlier Use of Mortality Has Decreased For Recipients Percutaneous Devices for MCS of Short Term Mechanical Support Stretch. JACC, 2014. Stretch. JACC, 2014. 9

12/17/16 A Team Approach To Evaluation Of The Pathway to Decision for Use of MCS Candidates For Advanced Mechanical Support Is Recommended • Heart failure/heart transplant specialist • Intensivist • Cardiac surgeon Peura Circulation, 2012. Considerations In Choosing Mechanical Support Thiele. Eur Heart J., 2015. 10