Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to...

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CardiogenicShock:PharmacologicalandMechanicalTherapy

ChristopherBarnettMD,MPH

Director,MedicalCardiovascularIntensiveCareUnitDirector,PulmonaryHypertensionProgram

Medstar HeartandVascularInstituteMedstar WashingtonHospitalCenter

Washington,DC

Case

• A55yearoldwithnoknownmedicalproblemspresentswithananteriorSTEMI5daysafterthestartofsymptoms.• Despitepromptrevascularizationandvasopressorsupporthypotensionpersistsand• AnIABPisinsertedwithtemporaryimprovementinhemodynamics.• Anechocardiogramdemonstratesaventricularseptaldefectandheistakenurgentlytotheoperatingroomforrepair.• PostoperativelyhemodynamicsdeteriorateandheisplacedonECMO.• SevendayslaterheisweanedoffECMOanddecanulated.• Heissubsequentlydischargedhomefromthehospital.

ShockisInadequateEndOrganPerfusionDespiteAdequateFluidResuscitation

• Criteriaforthediagnosisofcardiogenicshock• SBP<90for>30minutesorvasopressorneededtomaintainSBP>90• Pulmonarycongestion/elevatedLVfillingpressures• Signsofimpairedperfusion

• Mentalstatus• Coolextremities• Oliguria• Elevatedlactate

DifferentialDiagnosisofCardiogenicShockinPatientsintheCVICU

• Complicationsofacutemyocardialinfarction• Leftventriculardysfunction(80%ofcardiogenicshock)• VSD• Ventricularwallrupture• Acutevalvular heartdisease

• DecompensatedchronicHFrEF• HFpEF• Viralcardiomyopathy• Postcardiotomy• Arrhythmia• Valvular heartdisease• Rightventricularfailure

• Postoperativerightventricularfailure• Decompensatedchronicpulmonaryhypertension

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Don’tForgetAboutNon-CardiogenicCausesofShock!• Distributive• Sepsis

• Obstructive• Pulmonaryembolism

• Neurogenic• Spinalchordinjury

• Hypovolemic• Acutebloodloss• Intravascularvolumedepletion

MortalityinCardiogenicShockIsHigh

• SecondarytoacuteMI22-88%• Ventricularseptalrupture87%

• RightventricularfailurefromPAH30-48%

FactorsassociatedwithincreasedmortalityafteracuteMI:• Advancedage• Shockonadmission• Clinicalendorganhypoperfusion• Anoxicbraininjury• DecreasingSBP• PriorCABG• Non-inferiorAMI• Creatinine>1.9

Machuca.Circulation,2015.Reyentovich.NatReviewsCardiology,2016.

InitialCardiacDysfunctionLeadsToACascadeofDownstreamAbnormalities

Reyentovich.NatCVReviews,2016.

ApproachtoPatientsWithSuspectedCardiogenicShock• Optimizevolumestatus• Usevasopressorstomaintainadequatebloodpressuretopreventendorganischemiaanddysfunction• UseInotropes(inodilators)tooptimizecardiacoutput• Continuallyreevaluateresponsetotherapy• Considersurgicalrepairofstructuralheartdiseaseearly• Considerimplementationofmechanicalsupportearly

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SurvivalIsImprovedWithEarlyRevascularizationinSHOCKFromACS

Hochman.JAMA,2006.Hochman.NEJM,1999.

ItIsUnknownIfCulpritPCIIsSuperiortoMultivessel PCIInShock

http://www.culprit-shock.eu/the-project/

ThePulmonaryArteryCatheterIsUsefulCarefullySelectedPatientsWithCardiogenicShock• Escapetrial• FoundnotdifferenceinoutcomesbetweentherapyguidedwithPACorwithout• ExcludedDobutamineordopamine>3mcg/kg/min,anymilrinone,Cr>3.5

Binanay.JAMA,2005.Chaterjee.Circulation,2009.

AlphaAgonists:MechanismofAction

Overgaard.Circulation,2008.

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MechanismofAction:BetaAgonists

Overgaard.Circulation,2008.

VascularsmoothmuscleCardiacmyocyte

MechanismofPDE- Inhibitor:Milrinone

Overgaard.Circulation,2008.

Catecholaminergic ReceptorActivityDrug α β1 β2 DDopamine +++(3+) ++++(4+) ++(2+) +++++(5+)

Dobutamine +(1+) +++++(5+) +++(3+) NA

Norepinepherine +++++(5+) +++(3+) ++(2+) NA

Epinepherine +++++(5+) ++++(4+) +++(3+) NA

Isoproterenol 0 +++++(5+) +++++(5+) NA

Phenylepherine +++++(5+) 0 0 NA

Overgaard.Circulation,2008.

VasopressorsInCardiogenicShock:WhatChoiceIsBest?• Shocktrial:Increaseddeathwithdopamineincardiogenicshock• Posthocsubsetanalysisof280patients• Pressorchoicerequirescarefulconsiderationofindividualpatienthemodynamicstochoosetheoptimalvasopressor

DeBacker.NEJM,2010..

Deathat28days

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MechanismsandHemodynamicEffectsofIABP• Increaseddiastolicbloodflowtotheproximalaorta• Reducedafterloadduetovacuumeffectofballoondeflation

• ↓SBP• ↑DBP• ↑MAP• ↓HR• ↓PCWP• ↑CO• ↑Coronaryperfusion

HemodynamicBenefitsFromIABPVariesByPopulationStudied

Prodzinsky.Shock,2012.

HemodynamicBenefitsFromIABPVariesByPopulationStudied

Stone.JACC,2003.

RoutineUseOfAnIABPAfterAMIDoesNotImproveOutcomes

• 598patientswithhypotensionpulmonaryedemaandimpairedendorganperfusion• Nodifferenceinmortality• TrendtowardsbenefitinyoungerpatientswithoutpriorMIandanteriorMI

Theile.NEJM,2012.

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O’Gara.JACC,2013.

CurrentPercutaneousMechanicalSupportOptions

Theile.Eur HeartJ,2015.

CharacteristicsofTemporaryMechanicalSupportDevices

Reyentovich.NatReviewsCardiology,2016.

PatientFactorsToBeConsideredInMechanicalSupport• Irreversibleneurologicaldamage• Intracranialbleedingorotherconditionthatprecludesanticoagulation• Inaccessiblevesselsforcannulation• Irreversiblecardiopulmonaryfailureinpatientswhoarenocandidatesfortransplantation• Multiorgan dysfunction• Malignantdiseasewith<5yearlifeexpectancy• Potentialforrehabilitationandqualityoflifeafterrecovery

Machuca.Circulation,2015.

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Impella Device

Impella Registry:EarlyImplantationofImpella MayImproveOutcomes

O’Neill.JInt Cardiology,2014.

Impella Registry:EarlyImplantationofImpella MayImproveOutcomes

O’Neill.JInt Cardiology,2014.

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IMPRESStrialofImpella ComparedtoIABPInCardiogenicShock:NoDifferenceInMortality

Ouweneel.JACC.2016.

MetaAnalysisDemonstratesBetterHemodynamics,IncreasedComplications,SimilarOutcomes

Cheng.Eur HeartJ,2009.

MetaAnalysisDemonstratesBetterHemodynamics,IncreasedComplications,SimilarOutcomes

Cheng.Eur HeartJ,2009.

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FewDataToEvaluateECMO

Machuca.Circulation,2015.

TheUseOfMCSDevicesHasIncreasedDramatically

Stretch.JACC,2014.

MortalityHasDecreasedForRecipientsofShortTermMechanicalSupport

Stretch.JACC,2014.

ShiftToEarlierUseofPercutaneousDevicesforMCS

Stretch.JACC,2014.

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ATeamApproachToEvaluationOfTheCandidatesForAdvancedMechanicalSupportIsRecommended• Heartfailure/hearttransplantspecialist• Intensivist• Cardiacsurgeon

PathwaytoDecisionforUseofMCS

Peura Circulation,2012.

ConsiderationsInChoosingMechanicalSupport

Thiele.Eur HeartJ.,2015.