ACC/AHA Guidelines

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Cardiac Pulmonary Edema

and Cardiogenic Shock

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Frank-Starling Law

End-Diastolic Pressure

Str

ok

e V

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me

“In the normal heart, the diastolic volume (preload) is the principal force that

governs the strength of ventricular contraction.”

Otto Frank and Ernest Starling

ACC/AHA Guidelines

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Pulmonary Edema Flow

P : hydrostatic pressures

π : oncotic pressures

Kf : permeability constant of vessel wall

δ : reflection coefficient

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Pulmonary Edema

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HEMODYNAMIC CHANGESPROGRESSIVE LEFT HEART FAILURE

Hours

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Cardiogenic Shock

• Cardiogenic shock (CS) is a state of inadequate tissue perfusion due to cardiac dysfunction, and complicates 7-10% of cases of acute myocardial infarction

• Without treatment, cardiogenic shock is associated with a 70-80% mortality rate, and is the leading cause of death in patients hospitalized for an acute myocardial infarction

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Classic Criteria for Diagnosis of Cardiogenic Shock

1. Systemic Hypotension

systolic arterial pressure < 80 mmHg

2. Persistent Hypotension

at least 30 minutes

3. Reduced Systolic Cardiac Function

Cardiac index < 1.8 x m²/min

4. Tissue Hypoperfusion

Oliguria, cold extremities, confusion

5. Increased Left Ventricular Filling

Pulmonary capillary wedge pressure > 18 mmHg

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NRMI STEMI RegistryN=25,311

Frequency of Cardiogenic Shock : 7-9%

Babaev et al JAMA 2005 294:448

Frequency of CS Has Remained Steady Over Time

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Pathophysiology of Cardiogenic Shock

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Causes of Cardiogenic Shock SHOCK Trial and Registry (N=1160)

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Ventricular Septal Rupture

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Ventricular Septal Rupture

• Incidence 1-2%

• Timing 2-5 d p MI

• PE murmur 90%

• Thrill common

• Echo shunt

• PA cath O2 step up > 9%

• Echo

• IABP

• Inotropic Support

• Surgical Timing is

controversial, but

usually < 48 h

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Free Wall Rupture

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Free Wall Rupture

• Incidence: 1-6%

• Occurs during first week after MI

• Classic Patient: Elderly, Female, Hypertensive

• Early thrombolysis reduces incidence but

Late increases risk

• Echo: pericardial effusion, PA cath: equal diastolic pressure

• Treat with pericardiocentesis and early surgical repair

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Acute Mitral Regurgitation

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Management of Acute MR

• Incidence: 1-2%

• Echo for Differential Diagnosis:

– Free-wall rupture

– VSD

– Infarct Extension

• PA Catheter: large v wave

• Afterload Reduction

• IABP

• Inotropic Therapy

• Early Surgical Intervention

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Right Ventricular Infarction: DiagnosisRight Ventricular Infarction: Diagnosis

Clinical findings:

Shock with clear lungs,

Elevated JVP

Kussmaul sign

ECG:

ST elevation in R sided leads

Echo:

Depressed RV function

V4R

Modified from Wellens. N Engl J Med 1999;340:381.

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Management of RV Infarction

• Cardiogenic Shock secondary to RV Infarct has better

prognosis than LV Pump Failure

• IV Fluid Administration

• IABP

• Dobutamine

• Maintain A-V Synchrony

• Mortality with Successful Reperfusion = 2% vs. Unsuccessful = 58%

22Hochman et al NEJM 1999;341:625

The Shock Trial has been the most important study

for management guidelines in patients with

cardiogenic shock

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The SHOCK Trial (N=302)Randomization from Apr 1993-Nov 1998

Primary Endpoint: Overall 30 day mortality

Seconday Endpoints: 6 month and 1 year mortality

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SHOCK Trial

Primary and Secondary Endpoints

0

20

40

60

80

30 Days 6 months

Immediate

Revascularization

Strategy

Medical Stabilization

as an Initial Strategy

Primary Endpoint Secondary Endpoint

Mort

alit

y (

%)

46.7%

56.0%

50.3%

63.1%

P=.11

P= .027

Hochman et al, NEJM 1999; 341:625.

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PCI v. CABG in the Shock Trial

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SHOCK Trial: Age < 75

0

20

40

60

80

30 Day Mortality

41.4%

56.8%

%

P < .01

0

20

40

60

80

6 Month Mortality

44.9%

65.0%

Hochman et al, NEJM 1999; 341:625.

Immediate Revascularization Strategy

Medical Stabilization as an Initial Strategy

P < 0.002

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SHOCK Trial: Age > 75

0

20

40

60

80

30 Day Mortality

75.0%

53.1%

%

P < .01

0

20

40

60

80

6 Month Mortality

79.2%

56.3%

Hochman et al, NEJM 1999; 341:625.

Immediate Revascularization Strategy

Medical Stabilization as an Initial Strategy

P < 0.003

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• Mortality rates also decreased for those pts undergoing PCI

• Use of PCI increased from 27.4% to 54.4% (p < 0.001)

• Use of PCI was the strongest independent predictor of a lower in-hospital mortality (AOR 0.46; p < 0.001)

Babaev et al JAMA 2005 294:448

NRMI Revascularization Rates Over Time By Age

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6 Yr Outcome of SHOCK All Patients

Hochman et al JAMA 2006; 295:2511

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Cardiogenic ShockNRMI STEMI Registry (N=25,311)

• Age, 69.4 years

• Women, 42.6%

• Hypertension, 49.7%

• Diabetes, 27.2%

• Prior MI, 23.2%

• Prior CHF, 15.2%

• Prior PCI, 9.1%

• Prior CABG, 12.2%

Mortality Rates Over Time

Babaev et al JAMA 2005 294:448

0

10

20

30

40

50

60

70

1995 2004

60.3% 47.9%

P < 0.001

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Prognosis Is Worse With NSTEMIlikely related to the extent of underlying disease

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Multivariable Mortality Predictors

• Increasing age 1,2,3,4,7 and female gender7

• Lower left ventricular ejection fraction 4,6

• Chronic renal insufficiency7

• Initial6 and Final TIMI Flow grade 14

• Lower systolic blood pressure 1

• Diabetes mellitus 5

• Prior MI 2

• Increasing time from symptom onset to PCI 1,4

• Total Occlusion of the LAD 7Mitral regurgitation• Multivessel PCI (p = 0.040) 1,4,6

1 Webb et al JACC 2003;42:13802 Sutton Heart 2005;91:3393 Tedesco AHJ 2003:146; 472

4 Zeymer et al EHJ 2004;25:3225 Tedesco JV Mayo Clin Proc 2003; 78:5616 Sanborn JACC 2003:42; 1373

7 Klein et al AJC 2005; 96:35

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ACC/AHA Guidelines for Cardiogenic Shock

1. 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.

2. 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.

3. Echocardiography should be used to evaluate mechanical complications unless assessed by invasively

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ACC/AHA Guidelines for Cardiogenic Shock

Class IIa

1. Pulmonary artery catheter monitoring can be useful for the

management of STEMI patients with cardiogenic shock.

2. Early revascularization, either PCI or CABG, is reasonable for

selected patients > 75 years with ST elevation or new LBBB who

develop shock < 36 hours of MI and who are suitable for

revascularization that is performed < 18 hours of shock.

Patients with good prior functional status who agree to invasive care may be

selected for such an invasive strategy.

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CARDIOGENIC SHOCKMECHANICAL SUPPORT

• IABP Counterpulsation

• ECMO

• Ventricular assist devices

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IABP

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IABP support was associated with a ↓↓↓↓ in mortality:* NRMI-2 with lysis, from 67% to 49%

* SHOCK Trial, from 63% to 47%

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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 diseaseGrossman’s 2000

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ACC/AHA Guidelines for Cardiogenic Shock

Class I

1. 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.

2. Intra-arterial monitoring is recommended for the management of STEMI patients with cardiogenicshock.

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ECMOextracorporeal membrane oxygenation

extracorporeal life support

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ECMO

• Short-term cardiopulmonary support

• Buy time to decide the next step

– Recovery

– Transplantation

– Long-term device (ventricular assist device)

– Operation (CABG, pulmonary embolectomy,..)

– Give-up

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Ventricular Assist Devices

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Ventricular Assist Devices

• RVAD, LVAD, BiVAD

• Nonpulsatile pump

• Placed in parallel with RV, LV or both

ventricles

• Adjusted to provide total systemic flow of

2-3 L/min/M2

• Complications in 50% of patients:

– bleeding

– systemic embolism

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