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Evolving Algorithms for the Treatment
- f Acute MI Complicated by
Cardiogenic Shock
Advances in Heart Disease December 8, 2019
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Evolving Algorithms for the Treatment of Acute MI Complicated by - - PDF document
Evolving Algorithms for the Treatment of Acute MI Complicated by - - PDF document
Evolving Algorithms for the Treatment of Acute MI Complicated by Cardiogenic Shock Krishan Soni, MD, MBA Assistant Clinical Professor Division of Cardiology UCSF School of Medicine Advances in Heart Disease December 8, 2019 1 Disclosures
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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% Cardi dioge
- geni
nic S Shoc hock
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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 11
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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
- utcomes”
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Three interventions well studied…
Culprit Lesion Revascularization Multi-vessel Revascularization Intra-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.
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300 patients with shock due to LV failure complicating MI
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Randomly assigned to:
- Emergency revascularization
(CABG or angioplasty)
- Initial medical stabilization
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Primary end point: Mortality from all causes at 30 days.
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Secondary end point: Six-month survival.
No significant difference
Culprit Lesion Revascularization
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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.
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Non-significant difference in mortality at 30 days:
- 46.7% (revascularization)
- 56% (medical therapy);
- Difference: 9.3%, p=0.11
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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 Lesion Revascularization
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CULPRIT-SHOCK (2017)
Question: Does non culprit artery revascularization improve
- utcomes for patients presenting with acute myocardial infarction
(MI) and cardiogenic shock?
Thiele, H et al. NEJM (2018). DOI: 10.1056/NEJMoa1808788
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706 patients with AMI, multi- vessel disease and shock
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Randomly assigned to:
- Culprit lesion only PCI
- Immediate multi-vessel PCI
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Primary end point: death or renal- replacement therapy at 30 days
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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)
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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
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At one year:
- Death did not differ:
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50.0% (culprit only group) vs 56.9% (multi vessel)
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RR=0.88 [CI 0.76-1.01]
- Repeat revascularization higher for culprit only group
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32.3% vs 9.4%
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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
- utcomes 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
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Randomized prospective trial
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600 patients with CS and AMI
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All expected receive medical therapy and early revascularization
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Randomized to IABP or no IABP
Intra-aortic Balloon Pump (IABP)
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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 Revascularization Multi-vessel Revascularization Intra-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 Cardiol
- 2016. 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
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Rapidly identify patients with cardiogenic shock
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Measure hemodynamics pre PCI
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Use early mechanical support if LVEDP > 15 or cardiac index < 2.2
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Revascularization
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Measure
- Cardiac Power Output (CPO)
- Pulmonary Artery Pulsitility Index (PAPI)
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Wean or augment support based on CPO/PAPI
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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
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Age > 70 OR 2.41
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Lactate >4 OR 6.90
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CPO < 0.6 OR 3.79
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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 MCS Shock 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. 58
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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