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Importance of Complete Revascularization in Post Resuscitation Cardiogenic Shock
Karl B. Kern, MDProfessor of Medicine and The Gordon A. Ewy, MD Distinguished Endowed Chair of Cardiovascular MedicineCo-Director, Sarver Heart Center, Director, Cardiology Interventional FellowshipDivision of CardiologyUniversity of ArizonaDirector, Cardiac Catheterization LaboratoriesUniversity of Arizona Medical Center-University CampusTucson, Arizona
No Conflicts of Interest, financial or otherwise with this presentation
Karl B. Kern, MD
Cardiogenic Shock
Remains major risk for death with MI
Revascularization: the important Rx option
SHOCK Trial (Hochman): • 1st large RCT in Cardiogenic Shock in our Era
Death Rate between 50-70%
In the SHOCK Trial about 1/3 of patients had cardiac arrest
53%44%
Primary Endpoint : 30 Day Survival
p=0.11
47%
34%;
p=0.03
33% vs 20%;p=0.03
62% vs 44%
SHOCK Trial Lessons
Mortality remains high (50-70%)
Immediate Revascularization can help
Culprit vs Complete?
Cardiogenic Shock
SHOCK-2 Trial (Thiele)
IABP failed to improve outcome
Overall 30d mortality in this 2012 trial remained 40%
NEJM 2012;367:1287-96
Revascularization in Cardiogenic Shock
Culprit vessel or complete revascularization?
ESC 2012 STEMI Guidelines
European Heart Journal 2012;33:2569-2619
JACC 2011;58:692-703
Culprit-Only PCI Preferred Over Multi-vessel PCI in STEMI
Concern for additional injury from non-culprit vessel PCI:
Restenosis
Stent Thrombosis
Contrast Induced Nephropathy
All these studies excluded those with Shock
Few Acute Cardiac Conditions are More Deadly
Except the combination of:
STEMI patient,
Resuscitated from Cardiac Arrest,
with Subsequent Cardiogenic Shock
Figure 3. Predictors of 6-month survival after emergency PCI in resuscitated patients after cardiac arrest complicating AMI. Long intervals between the onset of cardiac arrest and
arrival of first responder and return of circulation are associated with increased death rate, whereas absence of shock, of diabetes, and of history of prior PCI were associated with
increased survival rate at follow-up.
Garot P et al. Circulation. 2007;115:1354-1362
Copyright © American Heart Association, Inc. All rights reserved.
OR of 12.66
Garot Overall Mortality post resuscitation = 40%
But with Cardiogenic Shock = 67%
Mooney Overall Mortality post resuscitation = 40%
With Cardiogenic Shock = 62%
How Do We Help These High Risk STEMI patients Resuscitated from Cardiac Arrest and now in Shock ?
Could Complete Revascularization with Multi-vessel PCI be the Answer for these
the “Sickest of the Sick” ?
JACC Intv 2013;6:115-25
Multicenter Prospective Observation Study of Consecutive STEMI Patients
Five French Centers Between 1998 and 2010 Inclusion:STEMIResuscitated from Cardiac ArrestCardiogenic Shock
Investigate the safety/efficacy of Multivessel primary PCI in such patients
Cardiogenic Shock
Systolic BP <90 mmHg for > 30 minor
Supportive measures required to maintain systolic BP >90 mmHg and evidence of end-organ hypoperfusion
Multivessel CAD
An additional significant stenosis (>70%) in a major (>2.5 mm diameter) non-Infarct related coronary artery
or A distal left main lesion with significant
stenosis in the ostia of both the LAD and the LCX.
?6 month survival
?6 month survival
First Data Substantiating the Concept that Complete Revascularization Could be Better than Culprit Only PCI for Multi-vessel Revascularization vs Culprit only in those with
STEMI, Cardiac Arrest, and Cardiogenic Shock
Myotte et al. (France) JACC Intv 2013;6:115-25
But What About Our Publically Reported Mortality Numbers?
0
0.5
1
1.5
2
2.5
3
UMC THH St J TMC NWH St M
In-Hosp 08
PCI Mortality Among Tucson Hospitals
HealthGrades.com
Publically reported Mortality Statistics will worsen
PCI “Mortality” • STEMI PCI 5%• Post Cardiac Arrest PCI 40%• Post Cardiac Arrest/Shock PCI 55%
Public perception of the institution /MD may suffer
Staff morale can improveMore neurologically-intact long-term survivors
If you do 100 STEMI PCI cases/yr: Expected overall mortality is 5%If you do 10 PCA STEMI PCI/yr: Expected overall mortality is 9%And if you do 10 PCA/Shock PCI/yr: Expected overall morality is nearly 12%
Expected Mortality:
Elective STEMI=5%PCA STEMI=40%PCA/Shock=55%
Editorial Catheterization & CV Intervention
Post Cardiac Arrest pts should be categorized as ‘compassionate use’ for PCI and not included in overall mortality calculations
Hospitals which excel in providing MTH and early intervention for post CA pts should be highlighted as centers of excellence not labeled as poor performers by current score card reporting
McMullan & White. Cath CV Interv 2010;76:161-163
Best for the Patient
Not worried about cost to society Not concerned about institutional or
physician’s statistics Wants the best chance for a positive,
neurological-intact, long-term survival
This requires early coronary angiography and PCI, including multivessel PCI in those with
Shock after Cardiac Arrest