cardiogenic shock ……………………….and then some

Cardiogenic Shock ……………………….and Then Some

SCAI C3 Summit Chicago May 12-13, 2006

“I’m Not Dead Yet”

Jeffrey F. Bleakley, University of Rochester

51 year old man with 45 minutes of chest pain associated with nausea, lightheadedness, and diaphoresis after lifting a sump pump

“I’m Not Dead Yet”: Presentation

• HTN• Hyperlipidemia• Strong family history of CAD• Current smoker

“I’m Not Dead Yet”: History

• Presented to Strong Memorial Hospital via EMS

• Noted to be diaphoretic and hypotensive with continuing chest pain

“I’m Not Dead Yet”: History

Cool, clammy and diaphoreticCool, clammy and diaphoretic

Alert and orientedAlert and oriented

JVP 12 cm above RAJVP 12 cm above RA

Rales at the bases bilaterallyRales at the bases bilaterally

No murmursNo murmurs

“I’m Not Dead Yet”: Physical

SCAI C3 Summit Chicago May 12-13, 2006Jeffrey F. Bleakley, University of Rochester SCAI C3 Summit Chicago May 12-13, 2006

• Given ASA, plavix, integrelin• Dopamine started for hypotension• Taken emergently to the cath lab

“I’m Not Dead Yet”: Management

RCA: occluded

• Blood pressure drops and patient becomes bradycardic after RCA injection.

• Pacemaker placed in anticipation of left coronary intervention.

LAD: severely diseased

Severe disease

• Discussed surgical approach, but less than enthusiastic response.

• Dopamine continued and titrated• Patient intubated for respiratory

decompensation• IABP placed.

Final angiogram

• Patient hypotensive and bradycardic requiring pacing

• Epinephrine and neosynephrine were given for blood pressure support

• Full ACLS protocol was followed including 5 Full ACLS protocol was followed including 5 minutes of chest compressionsminutes of chest compressions

• Finally, a 5 mg bolus of epinephrine was givenFinally, a 5 mg bolus of epinephrine was given

• Blood pressure and heart rate improvedBlood pressure and heart rate improved

• Patient stable enough for transportPatient stable enough for transport

• No evidence of VSD, MR or free wall rupture No evidence of VSD, MR or free wall rupture by echo; severely reduced LV function.by echo; severely reduced LV function.

• Admitted to the CCUAdmitted to the CCU• Became progressively more unstableBecame progressively more unstable• Continued inotropic supportContinued inotropic support• Had BIVAD placed in the early hours of the Had BIVAD placed in the early hours of the

morningmorning• Good urine output, followed commands, LFT’s Good urine output, followed commands, LFT’s

normal the following daynormal the following day

• Cardiac transplantation performed on 9/27/05Cardiac transplantation performed on 9/27/05• No signs of rejectionNo signs of rejection• Patient discharged home in stable condition Patient discharged home in stable condition

10/14/0510/14/05• Continues to do wellContinues to do well

“I’m Not Dead Yet”: Hospital Course

• Patient is in a band and is actively involved in Patient is in a band and is actively involved in local fundraisers for the cardiac transplant local fundraisers for the cardiac transplant program.program.

“I’m Not Dead Yet”: Follow-up

• SHOCK trial SHOCK trial • REMATCH trialREMATCH trial• Don’t give up!!!!Don’t give up!!!!

“I’m Not Dead Yet”: Take home points

• Patients were randomized to emergency Patients were randomized to emergency revascularization (n=1520 or medical revascularization (n=1520 or medical stabilization (n=150stabilization (n=150

• Primary endpoint was mortality at 30 daysPrimary endpoint was mortality at 30 days• Secondary endpoint was mortality at 6 monthsSecondary endpoint was mortality at 6 months

“I’m Not Dead Yet”: SHOCK trial

“I’m Not Dead Yet”: SHOCK

• Patients were randomized to receive a left Patients were randomized to receive a left ventricular assist device (n=68) or optimal ventricular assist device (n=68) or optimal medical therapy (n=61)medical therapy (n=61)

• Improved survivalImproved survival

• Improved quality of lifeImproved quality of life

“I’m Not Dead Yet”: REMATCH

• DON’T GIVE UP !!!!!!!!!!!!!!!!DON’T GIVE UP !!!!!!!!!!!!!!!!

“I’m Not Dead Yet”: Take Home

cardiogenic shock ……………………….and then some

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