Upload File

cardiogenic shock: pharmacological and mechanical therapy · impress trial of impellacompared to...

  • Home
  • Documents
  • Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis
10
12/17/16 1 Cardiogenic Shock: Pharmacological and Mechanical Therapy Christopher Barnett MD, MPH Director, Medical Cardiovascular Intensive Care Unit Director, Pulmonary Hypertension Program Medstar Heart and Vascular Institute Medstar Washington Hospital Center Washington, DC Case • A 55 year old with no known medical problems presents with an anterior STEMI 5 days after the start of symptoms. • Despite prompt revascularization and vasopressor support hypotension persists and • An IABP is inserted with temporary improvement in hemodynamics. • An echocardiogram demonstrates a ventricular septal defect and he is taken urgently to the operating room for repair. • Post operatively hemodynamics deteriorate and he is placed on ECMO. • Seven days later he is weaned off ECMO and decanulated. • He is subsequently discharged home from the hospital. Shock is Inadequate End Organ Perfusion Despite Adequate Fluid Resuscitation • Criteria for the diagnosis of cardiogenic shock • SBP <90 for >30 minutes or vasopressor needed to maintain SBP >90 • Pulmonary congestion/elevated LV filling pressures • Signs of impaired perfusion • Mental status • Cool extremities • Oliguria • Elevated lactate Differential Diagnosis of Cardiogenic Shock in Patients in the CVICU • Complications of acute myocardial infarction • Left ventricular dysfunction (80% of cardiogenic shock) • VSD • Ventricular wall rupture • Acute valvular heart disease • Decompensated chronic HFrEF • HFpEF • Viral cardiomyopathy • Post cardiotomy • Arrhythmia • Valvular heart disease • Right ventricular failure • Post operative right ventricular failure • Decompensated chronic pulmonary hypertension

Upload: others

Post on 22-Jul-2020

2 views

Category:

Documents


0 download

Report

TRANSCRIPT

Page 1: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

1

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

Page 2: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

2

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

Page 3: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

3

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.

Page 4: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

4

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

Page 5: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

5

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.

Page 6: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

6

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.

Page 7: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

7

Impella Device

Impella Registry:EarlyImplantationofImpella MayImproveOutcomes

O’Neill.JInt Cardiology,2014.

Impella Registry:EarlyImplantationofImpella MayImproveOutcomes

O’Neill.JInt Cardiology,2014.

Page 8: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

8

IMPRESStrialofImpella ComparedtoIABPInCardiogenicShock:NoDifferenceInMortality

Ouweneel.JACC.2016.

MetaAnalysisDemonstratesBetterHemodynamics,IncreasedComplications,SimilarOutcomes

Cheng.Eur HeartJ,2009.

MetaAnalysisDemonstratesBetterHemodynamics,IncreasedComplications,SimilarOutcomes

Cheng.Eur HeartJ,2009.

Page 9: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

9

FewDataToEvaluateECMO

Machuca.Circulation,2015.

TheUseOfMCSDevicesHasIncreasedDramatically

Stretch.JACC,2014.

MortalityHasDecreasedForRecipientsofShortTermMechanicalSupport

Stretch.JACC,2014.

ShiftToEarlierUseofPercutaneousDevicesforMCS

Stretch.JACC,2014.

Page 10: Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to IABP In Cardiogenic Shock: No Difference In Mortality Ouweneel. JACC. 2016. Meta Analysis

12/17/16

10

ATeamApproachToEvaluationOfTheCandidatesForAdvancedMechanicalSupportIsRecommended• Heartfailure/hearttransplantspecialist• Intensivist• Cardiacsurgeon

PathwaytoDecisionforUseofMCS

Peura Circulation,2012.

ConsiderationsInChoosingMechanicalSupport

Thiele.Eur HeartJ.,2015.


Cardiogenic shock 1

Cardiogenic shock

CLINICAL DOSSIER Cardiogenic Shockcardiogenicshock.com/assets/downloads/Clinical_Dossier.pdf4 Epidemiology of Cardiogenic Shock In cardiogenic shock, profound depression of myocardial

CLINICAL DOSSIER Cardiogenic Shock...Epidemiology of Cardiogenic Shock In cardiogenic shock, profound depression of myocardial contractility, results in the vicious spiral of reduced

7. Cardiogenic Shock

Cardiogenic Shock: Monitoring Methods and end Points · Cardiogenic Shock: Monitoring Methods and ... Non cardiogenic Edema Cardiogenic Edema ... CardShock-BE07.ppt Author: ewolf

Defining Cardiogenic Shock Identification of Pre-Shock and ... · Cardiogenic Shock Working Group Hemodynamic vs Hemo-Metabolic Shock C r

Cardiogenic shock PPV

INOTROPIC SUPPORT IN CARDIOGENIC SHOCK - ijn.com.my Support... · Institut Jantung Negara. CARDIOGENIC SHOCK •Cardiogenic shock occurs when adequate oxygen and ... -Cardiac tamponade-Acute

Cardiogenic Shock 2

Cardiogenic Shock in AMI

Kuliah Shock Cardiogenic

Cardiogenic Shock

Emergency lectures - Cardiogenic shock

Cardiogenic Shock and MI

Clinical Practice Guidelines: Cardiac/Cardiogenic shock · PDF fileClinical Practice Guidelines: Cardiac/Cardiogenic shock Disclaimer and copyright ... Cardiogenic shock is characterised

Cardiogenic Shock Ppt

Cardiogenic Shock - FINAL.ppt

PowerPoint Presentation · hypovolemic shock ... cardiogenic shock

Cardiogenic Shock and IABP

Cardiogenic Shock - Semantic Scholar€¦ · Cardiogenic Shock •Cardiogenic shock is characterized by a decreased pumping ability of the heart causing a shock-like state with inadequate

Cardiogenic Shock Ajar

Cardiogenic Shock - June_2017

Cardiogenic shock dr awadhesh

Shock Cardiogenic