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 No Conflicts of Interest No Financial Disclosures Krishan.soni@ucsf.edu 2 1 | [footer text here]

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 3 3 Latest Relevant Information § Major Society Statements and Guidelines 2017-2019 § Clinical Trials Published 2012-2019 4 2 | [footer text here]

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 5 5 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 6 6 3 | [footer text here]

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.” Diagnosis made by Physical Exam Biomarkers Hemodynamics 7 7 Hemodynamic Phenotypes Van Diepen, S, et al. Contemporary Management of Cardiogenic Shock. Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525 8 8 4 | [footer text here]

The Shock Spiral Van Diepen, S, et al. Contemporary Management of Cardiogenic Shock. Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525 9 9 Causes of Cardiogenic Shock Cardi dioge ogeni nic S Shoc hock Incidence of CS complicating AMI is ~ 6.5% to 10.1% 60-80% 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 10 10 5 | [footer text here]

Incidence of Cardiogenic Shock Increasing And in hospital mortality remains high Mandawat, A, et al. Circ Cardiovasc Interv . 2017;10:e004337. DOI: 10.1161/CIRCINTERVENTIONS.116.004337. 11 11 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 12 12 6 | [footer text here]

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. 13 13 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 14 14 7 | [footer text here]

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 15 15 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. 16 https://doi.org/10.1002/ccd.28329 16 8 | [footer text here]

Shock Stage Predictive of Mortality Mayo Clinic All CICU patients in shock 2007-2015 Jentzer, JC, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit. JACC 2019. Vol 73, 17, 2117-2128 17 17 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 18 18 9 | [footer text here]

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 19 19 Potential Shock Care Pathway “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” Van Diepen, S, et al. Contemporary Management of Cardiogenic Shock. Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525 20 20 10 | [footer text here]

Three interventions well studied… Culprit Lesion Multi-vessel Intra-aortic Balloon Revascularization Revascularization Pump (IABP) 1999: SHOCK 2017: CULPRIT-SHOCK 2012: IABP-SHOCK II 21 21 Culprit Lesion SHOCK Trial (1999) Revascularization Question : Does culprit vessel revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock? No significant difference 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. Hochman, JS e tal. N Engl J Med 1999;341:625-34. 22 22 11 | [footer text here]

Culprit Lesion SHOCK Trial (1999) Revascularization Question : Does culprit vessel revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock? Non-significant difference in mortality at 30 days : § - 46.7% (revascularization) - 56% (medical therapy); Establishes culprit - Difference: 9.3%, p=0.11 vessel revascularization as a standard Significant difference in mortality at 6 months : § strategy in - 50.3% (revascularization) managing AMI and - 63.1% (medical therapy); cardiogenic shock - Difference: 12.8%, p=0.027 Hochman, JS e tal. N Engl J Med 1999;341:625-34. 23 23 Multi-vessel CULPRIT-SHOCK (2017) Revascularization Question : Does non culprit artery revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock? 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 Thiele, H et al. NEJM (2018). DOI: 10.1056/NEJMoa1808788 24 24 12 | [footer text here]

Multi-vessel CULPRIT-SHOCK (2017) Revascularization Question : Does non culprit artery revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock? Multi-vessel PCI group had higher death and renal § failure at 30 days : - 45.9% (culprit only group) Results in guideline - 55.4% (multi vessel) p=0.01 changes to support infarct related vessel PCI only 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] § Thiele, H et al. NEJM (2018). DOI: 10.1056/NEJMoa1808788 25 25 IABP SHOCK II (2012) Intra-aortic Balloon Pump (IABP) § 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 Randomized prospective trial § 600 patients with CS and AMI § All expected receive medical § therapy and early revascularization Randomized to IABP or no § IABP Thiele, H et al. N Engl J Med 2012. DOI: 10.1056/NEJMoa1208410 26 26 13 | [footer text here]

IABP SHOCK II (2012) Intra-aortic Balloon Pump (IABP) 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 Thiele, H et al. N Engl J Med 2012. DOI: 10.1056/NEJMoa1208410 27 27 Three interventions well studied… Culprit lesion Multi-vessel Intra-aortic Balloon Revascularization Revascularization Pump (IABP) 28 28 14 | [footer text here]

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. 29 29 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 30 30 15 | [footer text here]