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1、Definition,90 mmHg,2.2 li/min.m2,15 mmHg,SHOCK Registry JACC Sept. 2000, Supp. A Spectrum of Clinical Presentations,5.6%,28%,65%,1.4%,Risk Factors for Cardiogenic Shock Due to AMI-mediated LV Dysfunction,Age 65 Female gender Large infarction Anterior infarction Prior infarction DM Prior HTN,Post-mor
2、tem study of Shock hearts,At least 40% of the myocardium infarcted in the aggregate (old and new injury) 80% have significant LAD disease 2/3 have severe 3Vdz,Outcomes of Cardiogenic Shock,Historic mortality 60-80% More recently reported mortality numbers 67% in the SHOCK trial registry 56% in GUSTO
3、-I (v.s. 3% in Pts. without shock),Outcomes of Cardiogenic Shock,The ST pattern in Cardiogenic shock: 15-30 % Non-ST elevation MI Older Mortality: 77% 70-85% ST elevations MI/ New LBBB Mortality: 53-63%,SHOCK registry findings on this point,Outcomes of Cardiogenic Shock,The SHOCK registry Similar mo
4、rtality in the two groups 62.5% in non-ST elevation 60.4% with ST elevation,Pathophysiology of Shock,Effect of Hypotension Flow in normal coronary: Regulated by microvascular resistance Coronary flow may be preserved at AO pressures as low as 50 mm Hg In coronary vessel with critical stenosis: Vasod
5、ilator reserve of microvascular bed is exhausted Decrease in AO pressure = Coronary hypoperfusion,Pathophysiology of Shock,Effect of Hypotension (continued) Normal heart extracts 65% of the O2 present in the blood Little room for augmentation of O2 extraction,Pathophysiology of Shock,Effect of: Elev
6、ated LVEDP on coronary flow,LVEDP (mm Hg),Pathophysiology of Shock,Hypotension + LVEDP and critical stenosis Myocardial Hypoperfusion LV dysfunction Systemic lactic acidosis Impairment of non-ischemic myocardium worsening hypotension.,Schematic,LVEDP elevation Hypotension Decreased coronary perfusio
7、n Ischemia Further myocardial dysfunction Neurohormonal activation Vasoconstriction Endorgan hypoperfusion,Medical Stabilization of Shock Pts.,Figure out the volume status, Swan if in doubt Air way Judicious afterload reduction Maintain AV synchrony Dont tolerate Afib Dual chamber pacing if A-V bloc
8、k present Correct Acid-Base disturbances Maintain BP ( IABP and/or Pressors).,Physiologic Effect of IABP in-vivo,Decreased afterload LV O2 consumption Williams, et.al., Circulation 1982 Kern, et.al., Circulation 1993 Coronary blood flow velocity was measured using doppler-wire in nine patients with
9、critical stenotic lesions. Peak diastolic coronary flow velocity beyond the stenosis was unaffected by intra-aortic balloon pumping. There was unequivocal IABP-mediated augmentation of both proximal and distal coronary blood flow velocities post PTCA.,Physiologic Effect of IABP in-vivo,Fuchs, et.al.
10、, Circulation, 1983 Great cardiac vein flow was measured in seven patients receiving maximal drug therapy and requiring balloon pumping for unstable angina. All patients had greater than 90% stenosis of the proximal LAD coronary artery. Increased great cardiac vein flow correlated with increased mea
11、n aortic diastolic pressure across changes in balloon volumes (off, 20 cc, 30 cc, and 40 cc) and changes in assist ratio (off, 1:4, 1:2, and 1:1) (p = .02).,Physiologic Effect of IABP in-vivo,Thus balloon pumping increased flow to a bed fed by the critical stenosis, or collateral vessels,IABP in Acu
12、te MI,JACC 1985,IABP in Acute MI,Pre-thrombolytic era No Lytics, ASA, or Lopressor 20 patients with Acute MI and “extensive myocardium at risk per baseline Thalium” were Randomized. Pt.s in Shock were excluded,Std. Rx: O2, MSo4, Lido, Heparin,Std Rx + IABP Plus IV NTG,IABP in Acute MI,Patients had r
13、epeat Thalium scan on Day-4 No differences were observed between the two groups regarding: -Thalium defect score comparing days 1 and 4 -The ejection fraction comparing days 1 and 4 = “Unlikely that a mortality benefit is conferred by the IABP/NTG combination”,Utility of IABP in Shock Pts.,Observed
14、clinical benefits: Improved acid-base status Improved urine output Improved mentation Improved overall hemodynamics,All this, however, does not add up to improved survival without Flow Restoration,Thrombolysis in Cardiogenic Shock,Rates of Reperfusion Lower, and Rates of Reocclusion Higher Than in n
15、on-shock pts Possible Reason: Diffusion of thrombolytic agent into the thrombus may be PRESSURE DEPENDENT.,BP Effect on efficacy of lytics in Shock,Dog data LAD occlusion by thrombus Hypotension induced by phlebotomy Prewitt JACC 1994; 23:784,Any Randomized Trials of Thrombolysis in Cardiogenic Shoc
16、k?,Most thrombolytic trials specifically excluded patients in cardiogenic shock The only large placebo-controlled thrombolytic study specifically examining Pts. presenting with shock was GISSI-1 Streptokinase = No Benefit,Combined IABP and Thrombolysis,GUSTO-I: IABP in 62 of the 310 lytic Rxd Pts. i
17、n shock,Observational Data:,Combined IABP and Thrombolysis,Kovack, et. al., JACC 1997 Stomel, et. al., Chest 1994 Two retrospective observational series from community hospitals: Improved survival from combination Rx.,Combined IABP and Thrombolysis,Observational Data from SHOCK Registery:,Combined I
18、ABP and Thrombolysis -Barron, et.al., AHJ June 2001 -National Registry of MI-2, Data base -21,178 pts. Presenting with or developing post-MI shock -32% Received IABP,P0.001,P=NS,TT,TT,IABP,PPTCA,PPTCA,IABP,The younger pts., twice as likely to get TT = Selection Bias,Combined IABP and Thrombolysis,Ac
19、companying Editorial by Magnus Ohman, and Judith Hochman: “Although, there is a wealth of physiologic and outcomes data to support the use of early IABP therapy in cardiogenic shock (in conjunction with lytics), randomized trials are clearly needed.”,Combined IABP and Thrombolysis,The only randomize
20、d trial on the subject: Thrombolysis and Counterpusion to Improve Cardiogenic Shock Survival (TACTICS): Results of a Prospective Randomized Trial. Magnus Ohman, et.al., Circulation Oct. 2000 Supp. Abstract,TACTICS,ST elevation MI patients, presenting within 12 hours of Sx, and Cardiogenic shock 57 P
21、atients were randomized,Thrombolytic Therapy alone,Thrombolytic Therapy + IABP,TACTICS,The primary endpoint of 6 month mortality was not statistically significant, P=0.3 Subgroup analysis: For KILLIP classes III and IV, P=0.07,PATIENT IS IN SHOCK w/ ST elevations, and 12 hrs Sx onset,IABP Pressors,M
22、ay increase the efficacy of Lytics,Administration of Lytics should not be delayed in anticipation of placement of IABP despite lack of randomized data proving efficay.,If EARLY REVASCULARIZATION is not to be pursued:,SHOCK Trial,Whether EARLY REVASCULARIZATION improves survival among patients with c
23、ardiogenic shock?,SHOCK Trial,302 Pts. with ST elevation (or new LBBB) and cardiogenic shock,Immediate Revascularization (CABG/PTCA),Late revascularization (if indicated) deferred for at least 54 hours,Within 36 hrs. of MI onset,Within 12 hrs. of Shock onset,SHOCK Trial: Primary end point, 30 days m
24、ortality,Diff.=9% P=0.11,47%,56%,Mortality,Diff.=13% P=0.027,50%,63%,52.4%,66.4%,Diff.=14% P0.02,Revasc.,Med Rx,SHOCK Trial Why wasnt the Primary end-point met?,Low mortality in the initial medical mgt gp. High rates of IABP use, 86% TT use, 63% Delayed revasculariztion, 21% Median of 104 hrs post r
25、andomization,30 days mortality,47%,56%,SHOCK Trial: Subgroup analysis, Age less than 75,Revasc.,Med Rx,P=0.02 CI1.0,P=0.002 CI1.0,Mortality,45%,65%,41%,56%,66.7%,48.4%,P0.02 CI1.0,SHOCK Trial: What to do with Pt.s older than 75,Total no. of Pt.s older than 75 y.o. = 56 (/302) The early revasculariza
26、tion groups had worse outcome at: 30 days (CI 1.0) 6 months( CI 1.0) 12 months, no difference in outcome,What to do with Pt.s older than 75,SHOCK Registry results is in contrast to the SHOCK Trial findings in this subgroup. Those older than 75 y.o., selected to undergo ERV had a survival advantage.
27、Case by case assessment in this population, and not across the board exclusion is called for.,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,SHOCK Trial:,Stent Placement,35.7%,52.3%,Role of IIb/IIIa inhibitors in Cardiogenic Shock,Retrospective subgroup analysis from the PURSUIT trial H
28、assade, et.al., JACC, 2000 Randomization to eptifibatide did not affect the incidence of shock Patients randomized to eptifibatide who developed shock had a significantly reduced incidence of death at 30 days A possible mechanism of benefit is relief of microvascular obstruction,Role of IIb/IIIa Inh
29、ibitors and Stents in Cardiogenic Shock,Long-Term Mortality Benefit With the Combination of Stents and Abciximab for Cardiogenic Shock Complicating Acute Myocardial Infarction Coronary Artery Disease Chan, Albert W. MD, MS; Chew, Derek P. MBBS; Bhatt, Deepak L. MD; Moliterno, David J. MD; Topol, Eri
30、c J. MD; Ellis, Stephen G. MD AJC Jan. 15, 2002,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Single center, non-randomized Data collected: Jan.1993 and June 2000 Thirty month follow-up available,96 Pt.s w/ Cardiogenic Shock,Stent + Reopro N=27,Stent Only N=14,PTCA+Reopro N=18,PTCA Onl
31、y N=37,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Thirty day Mortality Rates (%),Stent+ Reopro,Stent Only,PTCA+ Reopro,PTCA Only,Absence of Stent use: HR 2.39, 95% CI 1.22 to 4.67, p = 0.01,Absence of Abciximab use: HR 1.95, 95% CI 1.03 to 3.71, p = 0.04,On Univariate analysis:,EF =
32、30% HR 3.44, 95% CI 1.35 to 8.78, p = 0.01,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Use of Stents 29% Absolute mortality reduction 1 additional life saved for each 3-4 treated Patients.,Abciximab +Stenting 10% Absolute mortality reduction 1 additional life saved for each 10 patien
33、ts treated.,At 30 months,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Results of Primary Percutaneous Transluminal Coronary Angioplasty Plus Abciximab With or Without Stenting for Acute Myocardial Infarction Complicated by Cardiogenic ShockCoronary Artery DiseaseGiri, Satyendra MD, MP
34、H, MRCP; Mitchel, Joseph DO; Azar, Rabih R. MD, MSc; Kiernan, Francis J. MD; Fram, Daniel B. MD; McKay, Raymond G. MD; Mennett, Roger MSc; Clive, Jonathan PhD; Hirst, Jeffrey A. MD, MS AJC, 15 January 2002 .,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,This was a nonrandomized, prospe
35、ctive observational study. 113 (13.9%) were diagnosed with cardiogenic shock from 8/95 to 8/99.,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,No Reopro,With Reopro,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Multivariate Analysis,Role of IIb/IIIa Inhibitors and Stents i
36、n Cardiogenic Shock,Speculation: Greater use of Abxicimab, and Stents in the SHOCK Trial may well have resulted in a positive primary endpoint. The age cutoff of 75 may or may not have retained its significance vis-vis increased mortality.,Reversal of Cardiogenic Shock by Percutaneous Left Atrial-to
37、-Femoral Arterial Bypass Assistance,Holger, et.al, Circulation. 2001;104:2917. VADs were implanted in 18 consecutive patients who had cardiogenic shock after myocardial infarction A 21F venous cannula into the left atrium by transseptal puncture using TEE Pts served as their own controls All hemodyn
38、amic parameters showed significant improvement “The influence of this device on long-term prognosis warrants further investigation.”,Take Home Points,Combining Reopro with Stenting is likely to enhance the benefit of early revascularization. IABP helpful in stabilizing the Pt. Mitigates clinical sig
39、ns of SHOCK May improve outcome with concurrent Lytics No definitive evidence (randomized trials) showing improved outcomes with IABP/Lytic combinaiton.,Take Home Points,Nothing magical about the age cut off of 75, case by case assessment in this population is called for. If pt. is not a candidate for early revascularization, but is within12 hrs. of MI onset, administration of lytics (subject to risk-benefit assessment, age, grafts,) should not be delayed in anticipation of placement of IABP.,