evolving algorithms for the treatment of acute mi

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Evolving Algorithms for the Treatment of Acute MI Complicated by Cardiogenic Shock

Advances in Heart DiseaseDecember 8, 2019

Krishan Soni, MD, MBAAssistant Clinical ProfessorDivision of CardiologyUCSF School of Medicine

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Disclosures

No Conflicts of InterestNo Financial Disclosures

[email protected]

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Learning Objectives

§ Appreciate the incidence, etiologies, and outcomes associated with cardiogenic shock (CS)

§ Gain familiarity with a modern classification for cardiogenic shock

§ Understand data driven interventions and guidelines for managing patients with acute myocardial infarction (AMI) complicated by cardiogenic shock

§ Recognize how multidisciplinary team-based approaches may improve outcomes for patients with cardiogenic shock

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§ Major Society Statements and Guidelines 2017-2019

§ Clinical Trials Published 2012-2019

Latest Relevant Information

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Outline

§ Definition of shock and the shock spiral

§ A novel classification of shock (SCAI)

§ Interventions to treat AMI complicated by cardiogenic shock- Revascularization - Mechanical support therapies

§ Multidisciplinary team based approaches- National Cardiogenic Shock Initiative (NCSI)- Inova Shock Team

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Outline





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Traditional Definition of Cardiogenic Shock

“A state in which ineffective cardiac output (CO) due to a primary cardiac dysfunction results in inadequate end-organ

perfusion.”

Physical Exam Biomarkers Hemodynamics

Diagnosis made by

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Hemodynamic Phenotypes

Van Diepen, S, et al. Contemporary Management of Cardiogenic Shock. Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525

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The Shock Spiral


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Causes of Cardiogenic Shock

Jones TL, Nakamura K, McCabe JM. Cardiogenic shock: evolving definitions and future directions in management. Open Heart 2019;6:e000960. doi:10.1136/openhrt-2018-000960

60-80%

Incidence of CS complicating AMI is

~ 6.5% to 10.1%

Cardiogenic Shock

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Incidence of Cardiogenic Shock Increasing

Mandawat, A, et al. Circ Cardiovasc Interv. 2017;10:e004337. DOI: 10.1161/CIRCINTERVENTIONS.116.004337.

And in hospital mortality remains high

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Outline





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No standard for defining cardiogenic shock

Thiele, H, et Al. Management of cardiogenic shock complicating myocardial infarction: an update 2019. European Heart Journal (2019) 40, 2671–2683.

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SCAI Clinical Expert Consensus Statement Classification of Cardiogenic Shock

Society for Coronary Angiography and Intervention (SCAI)

Catheter Cardiovasc Interv. 2019; 1–9. https://doi.org/10.1002/ccd.28329

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Classification of Cardiogenic Shock

Baran, DA, Grines, CL, Bailey, S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Catheter Cardiovasc Interv. 2019; 1–9. https://doi.org/10.1002/ccd.28329

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Classification of Cardiogenic Shock

Baran, DA, Grines, CL, Bailey, S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Catheter Cardiovasc Interv. 2019; 1–9. https://doi.org/10.1002/ccd.28329

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Shock Stage Predictive of Mortality

Jentzer, JC, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit. JACC 2019. Vol 73, 17, 2117-2128

Mayo Clinic All CICU patients in shock 2007-2015

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Higher stages predict mortality regardless of shock etiology

Jentzer, JC, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit. JACC 2019. Vol 73, 17, 2117-2128

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Outline





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Potential Shock Care Pathway


“Despite improving survival in recent years, patient morbidity

and mortality remain high, and there are few evidence-based

therapeutic interventions known to clearly improve patient

outcomes”

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Three interventions well studied…Culprit Lesion

RevascularizationMulti-vessel

RevascularizationIntra-aortic Balloon

Pump (IABP)

1999: SHOCK 2017: CULPRIT-SHOCK 2012: IABP-SHOCK II

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SHOCK Trial (1999)Question: Does culprit vessel revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock?

Hochman, JS e tal. N Engl J Med 1999;341:625-34.

§ 300 patients with shock due to LV failure complicating MI

§ Randomly assigned to:- Emergency revascularization

(CABG or angioplasty) - Initial medical stabilization

§ Primary end point: Mortality from all causes at 30 days.

§ Secondary end point: Six-month survival.

No significant difference

Culprit LesionRevascularization

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SHOCK Trial (1999)Question: Does culprit vessel revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock?

Hochman, JS e tal. N Engl J Med 1999;341:625-34.

§ Non-significant difference in mortality at 30 days: - 46.7% (revascularization)- 56% (medical therapy); - Difference: 9.3%, p=0.11

§ Significant difference in mortality at 6 months:- 50.3% (revascularization) - 63.1% (medical therapy); - Difference: 12.8%, p=0.027

Establishes culprit vessel

revascularization as a standard

strategy in managing AMI and cardiogenic shock

Culprit LesionRevascularization

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CULPRIT-SHOCK (2017)Question: Does non culprit artery revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock?

Thiele, H et al. NEJM (2018). DOI: 10.1056/NEJMoa1808788

§ 706 patients with AMI, multi-vessel disease and shock

§ Randomly assigned to:- Culprit lesion only PCI- Immediate multi-vessel PCI

§ Primary end point: death or renal-replacement therapy at 30 days

§ Secondary end point: one year death from any cause, recurrent MI, repeat revascularization, re-hospitalization for CHF

Multi-vessel Revascularization

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CULPRIT-SHOCK (2017)

§ Multi-vessel PCI group had higher death and renal failure at 30 days: - 45.9% (culprit only group)- 55.4% (multi vessel) p=0.01

§ At one year: - Death did not differ:

§ 50.0% (culprit only group) vs 56.9% (multi vessel) § RR=0.88 [CI 0.76-1.01]

- Repeat revascularization higher for culprit only group§ 32.3% vs 9.4% § RR 3.44 [2.39-4.35]

Results in guideline changes to support

infarct related vessel PCI only

Question: Does non culprit artery revascularization improve outcomes for patients presenting with acute myocardial infarction (MI) and cardiogenic shock?

Thiele, H et al. NEJM (2018). DOI: 10.1056/NEJMoa1808788

Multi-vessel Revascularization

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IABP SHOCK II (2012)

§ Before 2012: Intra aortic balloon counter pulsation (IABP) was a class I treatment for cardiogenic shock complicating acute MI

§ Evidence was based mainly on registry data

Thiele, H et al. N Engl J Med 2012.DOI: 10.1056/NEJMoa1208410

§ Randomized prospective trial§ 600 patients with CS and AMI§ All expected receive medical

therapy and early revascularization

§ Randomized to IABP or no IABP

Intra-aortic Balloon Pump (IABP)

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Thiele, H et al. N Engl J Med 2012.DOI: 10.1056/NEJMoa1208410

Primary Outcome: Death at 30 days§ IABP group (39.7%) § Control group (41.3%) § RR 0.96, P = 0.69

No significant differences:§ Time to hemodynamic

stabilization§ Length of stay in ICU§ Serum lactate levels§ Renal function

IABP SHOCK II (2012) Intra-aortic Balloon Pump (IABP)

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Three interventions well studied…Culprit lesion

RevascularizationMulti-vessel

RevascularizationIntra-aortic Balloon

Pump (IABP)

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Percutaneous Assist Device Options

Thiele, H, et Al. Management of cardiogenic shock complicating myocardial infarction: an update 2019. European Heart Journal (2019) 40, 2671–2683.

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Percutaneous Assist Devices: Flow

Atkinson, TM, et al. A Practical Approach to Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention. JACC: Cardiovascular Interventions 2016 (9), 9: 871- 883

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Percutaneous Assist Devices: Hemodynamics


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Percutaneous Assist Devices: Complications


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• 287 consecutive unselected patients presented with AMICS and underwent PCI• Enrolled in the catheter-based ventricular assist device registry (cVAD)• Survival to discharge was 44%.

• Early implantation of a MCS device before PCI, and before requiring inotropes / vasopressors was associated with increased survival.

Basir, M, et al. Am J Cardiol 2016. http://dx.doi.org/10.1016/j.amjcard.2016.11.037

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Survival improved with earlier implantation of MCS therapy and reduction in use of inotropes

Basir, M, et al. Am J Cardiol2016. http://dx.doi.org/10.1016/j.amjcard.2016.11.037

cVAD Registry: Improved survival with MCS

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Percutaneous Assist Devices: Stop the Spiral


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Guideline Directed Management

2018 ESC/EACTS Guidelines on myocardial Revascularization. European Heart Journal (2019) 40, 87–165

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Guideline Directed Management - DO


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Guideline Directed Management – MAYBE DO


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Guideline Directed Management – DON’T DO


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Outline




§ Multidisciplinary team based approaches- National Cardiogenic Shock Initiative (NCSI)- Inova Heart Team

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Detroit Cardiogenic Shock Initiative (CSI)

O’Neil, W. A National Cardiogenic Shock Initiative (CSD). Slide Presentation. TCT 2017.

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Detroit CSI Protocol


GOALS§ Rapidly identify patients with

cardiogenic shock§ Measure hemodynamics pre PCI§ Use early mechanical support if LVEDP

> 15 or cardiac index < 2.2§ Revascularization§ Measure

- Cardiac Power Output (CPO) - Pulmonary Artery Pulsitility Index (PAPI)

§ Wean or augment support based on CPO/PAPI

§ Minimize Pressors/Inotropes

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Detroit CSI Protocol: Results


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National Cardiogenic Shock Initiative (NCSI)

O’Neil, W. Acute Cardiogenic Shock: The Number One Unresolved Challenge in Cardiovascular Disease. Slide Presentation. TCT 2910

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Lower CPO and higher inotrope requirement are associated with poor prognosis

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Bashir M, et al. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv. 2019;93:1173–1183.

Predictors of Mortality§ Age > 70 OR 2.41§ Lactate >4 OR 6.90§ CPO < 0.6 OR 3.79§ Creatinine >2 OR 3.75

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Mortality Rates in Shock over Time

Bashir M, et al. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv. 2019;93:1173–1183.

Pre PCI Post PCI MCSShock Team

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Shock team at Inova Heart and Vascular

Tehrani B, et al. Standardized Team-Based Care for Cardiogenic Shock. JACC 2019 (73) 13. https://doi.org/10.1016/j.jacc.2018.12.084

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Take Home Points

§ Cardiogenic shock is a spiral that involves an acute insult, poor cardiac function, and worsening end organ perfusion resulting in multi organ failure and death.

§ The 5 stages of shock are associated with increasing mortality and can be used to quickly risk stratify patients.

§ Guidelines support culprit vessel PCI in patients with acute myocardial infarction (AMI) and cardiogenic shock (CS). Multivessel PCI and use of IABP are no longer supported.

§ Multidisciplinary shock teams and the use of hemodynamics (and CPO) to inform use of MCS and reduce use of inotropes may result in lower mortality in cardiogenic shock.

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Temporal Trends in Mortality

Wayangankar et al. Trends in Post-ACS Cardiogenic Shock Patients. JACC Cardiovascular Interventions. 2 0 1 6 . Vol 9, 4, 3 4 1 – 5 1.

Patients with AMI and CS who are brought to the cath lab for PCI

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IMPRESS Trial (2017)

Ouweneel, D.M. et al. J Am Coll Cardiol. 2017;69(3):278–87.

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Cardiac Power


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Percutaneous Assist Devices: An Algorithm


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Potential Shock Care Pathway


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evolving algorithms for the treatment of acute mi

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