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Navin K. Kapur, MD, FACC, FSCAI, FAHA
Associate Professor, Department of Medicine
Interventional Cardiology & Advanced Heart Failure Programs
Executive Director, The Cardiovascular Center for Research & Innovation
Defining Cardiogenic ShockIdentification of Pre-Shock and Shock
Relevant Disclosures
Research Funding & Speaker/Consulting Honoraria:
Abiomed, Abbott, Boston Scientific, Maquet, Medtronic, MD Start, Cardiac Assist
Herbert J. Levine
Foundation
Tufts Medical Center
RO1HL139785, RO1H133215
Charlton Award
Tufts Medical Center
10/2007
Anterior MI
LAD PCI and IABPLVEF 20%
11/2007
ReadmittedHeart Failure
LVEF 25%
11/2007
Readmitted - HFICD Implanted
LVEF 25%
3/2008
ReadmittedRecurrent HF
LVEF 25%
4/2009
Readmitted – HF/ACS
Impella Supported
LAD and LCx PCI
LVEF 25%
7/2012
ReadmittedRecurrent HF
LVEF 20%
3/2015
ReadmittedRecurrent HF
LVEF 20%
12/2017
Cardiogenic Shock
Impella + VA-ECMOLVEF 10%
12/2017
Cardiogenic Shock
BiventricularCentrimags
LVEF 10%
4/2018
OrthotopicHeart Transplant
LVEF 65%
Which Cardiogenic Shock Are We Talking About?
AMI-Shock HR-PCI
Advanced HF-ShockAmbulatory Shock
Acute HF Syndromes
Modified from Goodlin. JACC 2009;54:386
Acute MI
Cardiogenic Shock
Advanced HF
Cardiogenic Shock
Which Cardiogenic Shock Are We Talking About?
Our Current Understanding of CGS Physiology
Founded in AMI-Shock
AHA Shock Consensus Statement Circ 2017
Coronary Problem
Ventricular Failure
Vascular Response
Defining Cardiogenic Shock: Exam + Swan
1970-1980s
Defining Cardiogenic Shock: Acute MI 1990
SHOCK Trial (1993-1998): Early Revasc vs Medical Therapy
• Clinical criteria
– SBP<90 mm Hg for at least 30 minutes or
– Supportive measures to maintain SBP>90 mm Hg
– Hypoperfusion (cool extremities, urine output of <30 ml per hour, and HR>60)
• Hemodynamic criteria
– Cardiac index < 2.2 LPM/BSA
– PCWP >15 mm Hg.
– Pulmonary-artery catheterization was not required if anterior MI with CHF.
• Early Shock:
– < 36 hours after myocardial infarction; randomization <12 hours after the
diagnosis of shock
• Exclusion Criteria:
– Severe systemic illness, mechanical or other cause of shock, severe valvular
disease, dilated cardiomyopathy, the inability of care givers to gain access for
catheterization, and unsuitability for revascularization.
Stretch and Bonde JACC 2014
Durable VADs Created Light at the End of the
Advanced HF Tunnel by Defining Patient Profiles
HM-II: BTT Trial
(NEJM 2007)
HM-II: DT Trial
HW: BTT Trial
INTERMACS Profiles : Heart Failure (Stage C-D)
Adapted from Stewart GC Circ 2011
Defining Cardiogenic Shock: Advanced HF 2000
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
BTR Rescue Therapy
2006-2007
2008-2010
2011-2013
INTERMACS Profiles Provided DefinitionData to Support The ‘Go vs No-Go’ Discussion
% o
f D
ura
ble
MC
S D
evic
e Im
pla
nts
Adapted from Kirklin et al JHLT 2014
Higher Mortality with INTERMACS 1 and 2 Patients > 65 years of Age
Rare use of Durable MCS as a Bridge to Recovery or Rescue Therapy Option
Acute MCS (pVADs) May Build that Bridge for
Cardiogenic Shock
Kapur et al Curr HF Rep 2016
Defining Cardiogenic Shock: Exam + Swan
2017 – Back to Killip and Forrester
Time in Cardiogenic Shock
Rx: Multi-organ Support
Unloading, Ventilator, CVVHD
Hemo-Metabolic Problem
Rx: Hemodynamic Support
Circulatory and Ventricular
Hemodynamic Problem
Recovery Death
Kapur and Esposito Curr Cardio Risk 2016 Kapur and Esposito F1000 2017
An Issue of Timing: Diagnosis, Stratification, Therapy
Hemodynamic vs Hemo-Metabolic Shock
Simplifying the Algorithm for AMI-Shock
William O’Neill and Michael Hacala
The Cardiogenic Shock Working Group
Largest US registry of Acute MCS device use in Cardiogenic Shock
Over 500 patients with PA Catheter
Indices
<14 ≥140
20
40
60
80
100
Right Atrial PressureM
ort
ality
(%
)
GFR>47
GFR£47
Renal Profile
p=0.01
p=0.18
p=0.056
p=0.001
p=0.07
<14 ≥140
20
40
60
80
100
Right Atrial Pressure
Mo
rtality
(%
)
Non-Mixed
Mixed
LFT Profile
p=0.01
p=0.15
p=0.45
p=0.004
p=0.15
<14 ≥140
20
40
60
80
100
Right Atrial Pressure
Mo
rtality
(%
)
Non-Mixed
Mixed
LFT Profile
p=0.01
p=0.15
p=0.45
p=0.004
p=0.15
<14 ≥140
20
40
60
80
100
Right Atrial Pressure
Mo
rtality
(%
)
GFR>47
GFR£47
Renal Profile
p=0.01
p=0.18
p=0.056
p=0.001
p=0.07
Morine & Kapur et al. Shock Working Group
Late ShockDeep ShockSevere Shock
Hemo-MetabolicShock
Pre-ShockEarly ShockMild Shock
HemodynamicShock
Hemodynamic vs Hemo-Metabolic Shock
Cardiogenic Shock Working GroupHemodynamic vs Hemo-Metabolic Shock
Cr<1.41 Cr≥1.41 Cr<1.41 Cr≥1.410
20
40
60
80
100
Mo
rtality
(%
)
Impella
ECMO
RAP<14 RAP³14
26 19 19 19 28 32 34 48
*
Cardiogenic Shock Working Group
p=0.09p<0.01
Morine & Kapur et al CSWG TCT 2018
In-H
osp
ital
Mo
ralit
y (%
)
Predictors of Survival at 12-24 hours (N=75)
LA
CTA
TE
CARDIAC POWER OUTPUT
> 0.6
≥4
<4
≤ 0.6
63% Survival
(n=5/8)
30% Survival
(n=3/10)
80% Survival
(n=8/10)
96% Survival
(n=45/47)
Courtesy of William O’Neill
Cardiogenic Shock InitiativeHemodynamic vs Hemo-Metabolic Shock
Strom and Yeh et al. Eurointerv 2018
A Shift in Acute MCS for Cardiogenic Shock
In-hospital Mortality:
MCS vs Non-MCS
33% vs 42%
p<0.001
