acute heartfailure & cardiogenic shock · prognosis as cardiogenic shock. •htn if present is...

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Acute Heart Failure & Cardiogenic Shock

Stuart Hutchison, MD, FRCPC, FACC, FAHA, FASE, FSCCT, FSCMR

Professor of Medicine, Departments of Cardiac Sciences,

Internal Medicine & Radiology

University of Calgary


Relationships with Financial Sponsors:

- Grants or Research Support: None

- Speakers Honoraria: None

- Consulting Fees: None

- Patents: None

- Other: None

Faculty Presenter Disclosure

Cardiology for the Non-Cardiologist

Faculty: Stuart Hutchison


Potential for conflicts of interest: None

Disclosure of Financial Support

Cardiology for the Non-Cardiologist has received financial support from Pharmaceutical companies Bayer, Bristol-Meyers Squibb/Pfizer, Servier, Novartis, Amgen, AstraZeneca and Merck in the form of unrestricted educational grants.


• While we have received unrestricted educational grants from several pharmaceutical companies, most presentations have no mention of specific products and are unrelated to the supporting companies or their products. No specific presentations will be supported or sponsored by a specific company.

• Information on specific products will be presented in the context of an unbiased overview of all products related to treating patients.

• All scientific research related to, reported or used in this CME activity in support or justification of patient care recommendations conforms to the generally accepted standards.

• Clinical medicine is based in evidence that is accepted within the profession.

Mitigating Potential Bias

Click to edit Master title styleThis presentation contains the following caveat that:

Click to edit Master title styleAcute Heart Failure & Cardiogenic Shock

• Causes of …

• …. Use of Echo

• Clinical parameters discussion

• Intubation issues in cardiogenic shock

• Choices of vasopressors, inotropes

• Non-Hypotension+APE = BiPap + NTG

• Mechanical support

• A.fib alone does not cause CHF

• RV Infarction management

• Several cases from the last 6 months

Click to edit Master title styleCauses of Cardiogenic Shock: LV/Left Heart

• STEMI

• NSTEMI

• 2nd or 3rd MI • (“Mechanical” Complications of MI)

• Takotsubo / Stress Cardiomyopathy

• DCM, advanced

• Fulminant Myocarditis

• HOCM + a problem

• Valve• Chronic lesion, now advanced• Acute:

• Infective endocarditis• AAD / AI• Leaflet Rupture in MVP

• Prosthetic Valve Dysfunction • Bioprostheses: Tears, Dehissences• Mechanical Prostheses: Thrombosis,

Dehissences

Click to edit Master title styleCauses of Cardiogenic Shock: RV/Right Heart

• RV MI (Inferior STEMI)

• Tamponade

• Massive PE

• DCM / RCM / Constriction + a.fib

Click to edit Master title styleCauses of Cardiogenic Shock: Mixed RV/ LV

• DCM

• Post-cardiac arrest stunning

Click to edit Master title styleEchocardiography: Yes – Lots of it!

• Urgent call to Echolab

• “Point of Care Bedside Echo”

Click to edit Master title styleUseful Clinical Parameters

• Heart Rate (sinus):• Be very concerned with marked sinus tachycardia in the context

of hypotension.• For the most part, it bespeaks attempted compensation. The lower the

BP, the more the compensation is failing.

• Hence, no rate lowering medications, and be much more assertive in calling for assistance.

• 140 bpm is maxed out compensation.


• Blood Pressure:• Marked dissociation of BP and cardiac index – there is no linearity

to the BP:CI association (SHOCK Trial Registry); there is little assurance in many BPs in the 90-100 range.

• You never knew the baseline. A fall in BP by 40% has the same prognosis as cardiogenic shock.

• HTN if present is obviously useful as it is intervenable easily (NTG). BP >180mmHg in acute pulmonary edema has a much lower intubation rate (if you lower the BP to 100 mm Hg you half the afterload and double the ejection).


• Extremities:• Warm versus Not Warm / Cool – best immediate bedside finding

of tissue perfusion / degree of elevation of SVR.

• Hands far more useful than feet (PVD confounds).

• Highly predictive of outcome.

• Urine output:• As a marker of tissue perfusion takes time to gauge. You are often

against time.


• Lactate levels are useful, so if query cardiogenic shock, perform sequentially, but:

• Lactate takes time to rise, and its clearance is influenced by hepatic function, which is influenced by both hepatic under perfusion and hepatic congestion.

Click to edit Master title styleOther Still Useful Clinical Parameters

• Crepitations:• Chest radiography has a 20% incremental detection rate for pulmonary

edema compared to physical exam in non-shock cases, and a 40% incremental detection rate compared to physical exam in pulmonary edema shock cases.

• Murmurs:• Are golden findings, but are hard to appreciate amongst the dim and

clamour of the ER, and are softer and shorter the worse the MR or AI, and may be absent in torrential MR / AI.

• Send the case in the direction of valvular disease, post infarction septal ruptures…


Shotgun blast against the wall

JACC


• A 50% fall in net forward stroke volume is fatal, unless reversed.

• Normal EF is 55-60%. The average EF of fatal cardiogenic shock due to AMI is 32% (SHOCK Trial Registry).

• The “100 Thing”: A BP < 100 mm Hg and a HR > 100 bpm has essentially the same natural history as does cardiogenic shock.

Click to edit Master title styleIntubation in Cardiogenic Shock

• More benefits than controlling oxygenation.• Alleviating the distress lowers the heart rate

• (With paralysis) cardiac index is redistributed away from the diaphragm.

• Intubate earlier• When the situation is still controlled or somewhat controlled

• Pre-transport

• Pre-cardiac catheterization


• Drugs:

• Avoid or use small amounts only of vasoplegic drugs:• Propafol

• Midazolam


• Drugs:

• “Cardiac Induction”• Fentanyl:

• Dose: 200 – 500 micrograms

• Ketamine:

• Dose: 0.5 – 2.0 mg/kg if adjuvant drugs are used

• 2.0 - 4.5 mg/kg if use alone

• Sympathomimetic hemodynamic effects, generally, (some paradoxical reactions).


Ketamine


• Paralysis:• Benefits dominate:

• Better control of ventilation

• 20% of cardiac index redirected away from diaphragm and external intercostal muscles - now available to the rest of the body

• 2 ml O2 per min per 1 gm of muscle at peak work

• Also, elimination of the high A-V O2 extraction by respiratory muscles

• Less histaminic release with rocuronium

Click to edit Master title styleIntubation - Ventilation

• PEEP:• Improves Oxygenation:

• Alveolar recruitment by opening airways

• ± Redistribution of lung water

• Reduces intrapulmonary shunting, by matching ventilation to perfusion

• But, Alters Hemodynamics:• Decreases RV and LV preload

• Increases RV afterload

• The effect of which depends on the nature of the cardiac dysfunction.

Click to edit Master title styleIntubation

• Have your inotrope/pressor drugs already running, if you have time, before you intubate.

• Be comfortable with IV boluses.

Click to edit Master title styleInotropes and Pressors in Cardiogenic Shock

• Epinephrine

• Norepinephrine

• Dopamine

• Dobutamine, Milrinone

• Phenylephrine


• Epinephrine

• Norepinephrine

• Dopamine


• Phenylephrine

Nobel Prize for Medicine /

Physiology in 1970.


• Epinephrine

• Norepinephrine

• Dopamine


• Phenylephrine

The choice of which depends on:

- Heart Rate

- Blood Pressure / Perfusion

- Pulmonary Edema

- Ectopy


Dopamine Dobutamine Dopamine Dobutamine

Incre

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iac I

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ex (

%)

0 1

0

20

3

0

40

50

Delt

a W

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ge P

ressu

re (

%)

-20

-10

0

10

20

30

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50

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______________________________

Chest 1986;89(5):636-40.

Click to edit Master title styleMechanical Hemodynamic Support

• Intra-Aortic Balloon Pump (0.8 l/min/m2)

• Impella (3.5 l/min)

• VA (Veno-Arterial) ECMO (6 l/min, plus oxygenation)

Click to edit Master title styleRV Infarction

• 90% of hypotension and 95% of CGS in inferior STEMI– RV infarction can be the presumed etiology.

• Establish CVP of 15 cm H20, central line confirmed

• Dobutamine / Epinephrine

• PCI

• Maintain AV synchrony• Cardiovert out of atrial fibrillation

• AV sequential pacing

Click to edit Master title styleAtrial Fibrillation Alone Does Not Cause CHF

• You can reliably assume that there is underlying structural heart disease:

• DCM >> Valvular

• Check the CXR for cardiomegly

• Avoid IV diltiazam until DCM excluded

Click to edit Master title styleAcute Pulmonary Edema & Non-Hypotension or Hypertension

• Nitroglycerine, plus• Use nitrospray more often because it is faster to deliver than is IV NTG, and

is more potent than IV NTG (as IV NTG seems too often be given). • Use nitropatches as well as they are more potent than IV NTG (as IV NTG

seems too often be given).• If you use IV NTG, use enough: start at a reasonable dose and up-titrate q3-5

minutes. Up-titrate to systolic BP / afterload reduction target.

• BiPAP• Reduces intubation rate (OR 0.32 [0.17-0.59], NNT: 7), see

following.• Reduces the hospital mortality rate (OR 0.33 [0.18-0.59], NNT: 8), see

following.• May reduce early (hosptial) mortality, but not later mortality (40% 1 year),

which is due to the cause of the pulmonary edema.Roguin A, Behar D, Ben Ami H, Reisner SA, Edelstein S, Linn S, et al.Long-term prognosis of acute pulmonary oedema--an ominous outcome. Eur J Heart Fail 2000;2:137-44

Click to edit Master title styleReduction of Intubation Rates:

BiPaP vs Standard Medical Therapy

Agarwal R, Aggarwal AN, Gupta D, Jindal SK. PMJ/BMJ 2005;81(90)

Click to edit Master title styleReduction of Hospital Mortality:

BiPaP vs Standard Medical Therapy


Click to edit Master title styleReduction of Intubation Rates:

CPAP vs BiPaP


Click to edit Master title styleReduction of Hospital Mortality:

CPAP vs BiPaP


Click to edit Master title styleCase 1: 19 year old female

• CC: weak and SOB x 1 week

• 80/50 mm Hg, 145 bpm, 45/min

• Cool, decreased mentation, oliguric

• Sinus tachycardia

• CXR: mild cardiomegaly, pulmonary edema

• Lactate: 12 mmol/L

• Troponin 60 ng/L

• Echo: Severe biventricular systolic dysfunction


• CC: weak and SOB x 1 week

• 80/50 mm Hg, 145 bpm, 45/min

• Cool, decreased mentation, oliguric

• Sinus tachycardia

• CXR: mild cardiomegaly, pulmonary edema



• Echo: Severe biventricular systolic dysfunction

Norepinephrine

Intubate

VA ECMO in ER

Click to edit Master title styleCase 2: 57 year old male

• CC: CP and SOB x 4 hours

• 80/50 mm Hg, 125 bpm, 40/min

• Not warm

• Sinus tachycardia, Anterior STEMI

• CXR: pulmonary edema




• CC: CP and SOB x 4 hours

• 80/50 mm Hg, 125 bpm, 40/min

• Not warm


• CXR: pulmonary edema



Norepinephrine

Intubate

To Cath Lab:

- IABP -

- IMPELLA

- Survived.


• CC: CP and Syncope

• 80/50 mm Hg, 70 bpm, 30/min

• Not warm, JVD

• Sinus tachycardia, Inferior STEMI

• CXR: clear lung fields




• CC: CP and Syncope

• 80/50 mm Hg, 70 bpm, 30/min

• Not warm, JVD

• Sinus tachycardia, Inferior STEMI

• CXR: clear lung fields



Volume

Epinephrine

Intubate

To Cath Lab:

- IABP

- PCI


• CC: palpitations x 1 week, SOB x 3 days

• Hadn’t seen an MD for 25 years

• 235/120 mm Hg, 145 bpm irreg, 30/min

• Warm

• Atrial fibrillation RVR 165 bpm

• CXR: Cardiomegaly & Mild pulmonary edema

• Lactate: normal



• CC: palpitations x 1 week, SOB x 3 days

• Hadn’t seen an MD for 25 years

• 235/120 mm Hg, 145 bpm irreg, 30/min

• Warm

• Atrial fibrillation RVR 165 bpm

• CXR: Cardiomegaly & Mild pulmonary edema

• Lactate: normal


Nitrospray x 4

Preparing for BiPaP…

BP to 115 systolic –

much improvement

Metoprolol/Digoxin IV

NTP 0.6 mg/hr, toward


Infrequent Cases do Show-Up as Well

On the Same Day…….

Click to edit Master title styleCase 5: 56 year old male, 9 AM

• OHCA

• CC: CP 1 hour at work, collapse

• 85/40 mm Hg, 110 bpm, ventilated

• Not warm


• CXR: mild pulmonary edema



Click to edit Master title styleCase 5: 56 year old male, 9 AM

• OHCA

• CC: CP 1 hour at work, collapse

• 85/40 mm Hg, 110 bpm, ventilated

• Not warm


• CXR: mild pulmonary edema



Epinephrine

To Cath Lab:

- PCI: Improved BP

To CCU:

- Cooling

- BP fall to 70, 5PM

- Echo: Effusion±FWR

To OR, 11PM:

- LV Patch Repair

- … Survived

Click to edit Master title styleCase 6: 62 year old male, noon

• CC: CP x 4 days, SOB (sudden x 2 hours)

• 95/50 mm Hg, 130 bpm, 60 /min

• Warm

• Sinus tachycardia, Anterior ST Depression

• CXR: pulmonary edema ++++



• POC US: Hyperdynamic LV

Click to edit Master title styleCase 6: 62 year old male, noon

• CC: CP x 4 days, SOB (sudden x 2 hours)

• 95/50 mm Hg, 130 bpm, 60 /min

• Warm

• Sinus tachycardia, Anterior ST Depression

• CXR: pulmonary edema ++++



• POC US: Hyperdynamic LV

Intubate

Norepinephrine

To Cath Lab:

- 90% LCx

- MR

- IABP

TEE in Cath Lab:- Papillary muscle rupture

To OR 8PM:

- Mitral valve replacement

- Survived

Click to edit Master title styleThanks to …

• Kelsey Ragan (ER resident) for her help and suggestions about topics.

acute heartfailure & cardiogenic shock · prognosis as cardiogenic shock. •htn if present is...

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