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Cardiogenic Shock Diagnosis, Treatment and Guidelines

Cardiogenic Shock Diagnosis, Treatment and Guidelines. Mladen I. Vidovich, MD April 5, 2007. H & P. 60 yo m >24 h of substernal chest pain Associated with mild dyspnea Continued to watch TV The following day – came to NMH ED. PMH. CVA – 10 yrs ago Syncope, hospitalized ’04, refused w/u

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Cardiogenic Shock Diagnosis, Treatment and Guidelines

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  1. Cardiogenic ShockDiagnosis, Treatment and Guidelines Mladen I. Vidovich, MD April 5, 2007

  2. H & P • 60 yo m • >24 h of substernal chest pain • Associated with mild dyspnea • Continued to watch TV • The following day – came to NMH ED

  3. PMH • CVA – 10 yrs ago • Syncope, hospitalized ’04, refused w/u • “psychiatric disorder, NOS • Cataracts • NKDA • TOB – 2-3 ppd x many • FH – unable to obtain

  4. PE • Speaks in full sentences, initially refusing cath/PCI • Cold, mottled, clammy skin • HR 40-50, RR 20-30, BP 80/50, AF • Neck – no overt JVD • Lungs – B crackles 1/3 • CV – RRR, no m • Abdomen – obese benign • No edema

  5. ECG ?

  6. CATH

  7. CATH • During catheterization patient’s breathing became very laborious along with profound acidemia (6.98/44/71) • Urgently intubated • Asystole/3rd degree AVB/hemodynamically stable VT • TPM • PA catheter– PCWP 30, PAP 60 • IABP

  8. Cardiogenic Shock

  9. Classic Criteria for Diagnosis of Cardiogenic Shock • Systemic Hypotension systolic arterial pressure < 80 mmHg • Persistent Hypotension at least 30 minutes • Reduced Systolic Cardiac Function Cardiac index < 1.8 x m²/min • Tissue Hypoperfusion Oliguria, cold extremities, confusion • Increased Left Ventricular Filling Pulmonary capillary wedge pressure > 18 mmHg

  10. Ventricular Septal Rupture Management • Echo • IABP • Inotropic Support • Surgical Timing is controversial, but usually < 48°

  11. Free Wall Rupture • Occurs during first week after MI • Classic Patient: Elderly, Female, Hypertensive • Early thrombolysis reduces incidence but Late increases risk • Treat with pericardiocentesis and early surgical repair

  12. Acute MR Management • Echo for Differential Diagnosis: • Free-wall rupture • VSD • Infarct Extension • PA Catheter • Afterload Reduction • IABP • Inotropic Therapy • Early Surgical Intervention

  13. SHOCK TrialPrimary and Secondary Endpoints P= .027 P=.11 63.1% 56.0% 50.3% Mortality (%) 46.7% Primary Endpoint Secondary Endpoint Hochman et al, NEJM 1999; 341:625.

  14. Cardiogenic Shock Outcome P=0.04 Antman et al. JACC 2004; 44: 671

  15. Hochman et al, NEJM 1999; 341:625.

  16. Hochman et al, NEJM 1999; 341:625.

  17. SHOCK Trial: Age < 75 Immediate Revascularization Strategy Medical Stabilization as an Initial Strategy P < 0.002 P < .01 65.0% 56.8% % 44.9% 41.4% 30 Day Mortality 6 Month Mortality Hochman et al, NEJM 1999; 341:625.

  18. SHOCK Trial: Age > 75 Immediate Revascularization Strategy Medical Stabilization as an Initial Strategy P < 0.003 P < .01 75.0% 79.2% 56.3% 53.1% % 30 Day Mortality 6 Month Mortality Hochman et al, NEJM 1999; 341:625.

  19. 30-Day Mortality According to Patient Subgroup Hochman, J. S. et al. N Engl J Med 1999;341:625-634

  20. SHOCK Registry: Impact of Thrombolytics and IABP P<0.0001 77% 63% 52% % 47% Thrombolytics + IABP No Thrombolytics + IABP Thrombolytics + No IABP Neither In Hospital Mortality Hochman et al, NEJM 1999; 341:625.

  21. IABP

  22. Contraindications to IABP • Significant aortic regurgitation • Abdominal aortic aneurysm • Aortic dissection • Uncontrolled septicemia • Uncontrolled bleeding diathesis • Severe bilateral peripheral vascular disease uncorrectable by peripheral angioplasty or cross-femoral surgery • Bilateral femoral-popliteal bypass grafts for severe peripheral vascular disease Grossman’s 2000

  23. RV Infarction Management • Cardiogenic Shock secondary to RV Infarct has better prognosis than LV Pump Failure • IVF Administration • IABP • Dobutamine • Maintain A-V Synchrony • Mortality with Successful Reperfusion = 2% vs. Unsuccessful = 58%

  24. ACC/AHA Guidelines 2004 Hochman Circ 2003: 107:298

  25. ACC/AHA Guidelines for Cardiogenic Shock Class I • IABP is recommended for STEMI patients when cardiogenic shock is not quickly reversed with pharmacological therapy. The IABP is a stabilizing measure for angiography and prompt revascularization. • Intra-arterial monitoring is recommended for the management of STEMI patients with cardiogenic shock.

  26. ACC/AHA Guidelines for Cardiogenic Shock Class I • Early revascularization, either PCI or CABG, is recommended for patients < 75 years old with ST elevation or new LBBB who develop shock unless further support is futile due to patient’s wishes or unsuitability for further invasive care. • Fibrinolytic therapy should be administered to STEMI patients with cardiogenic shock who are unsuitable for further invasive care and do not have contraindications for fibrinolysis. • Echocardiography should be used to evaluate mechanical complications unless assessed by invasively

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