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1、Definition,90 mmHg,2.2 li/min.m2,15 mmHg,SHOCK Registry JACC Sept.2000,Supp.A Spectrum of Clinical Presentations,5.6%,28%,65%,1.4%,Risk Factors for Cardiogenic Shock Due to AMI-mediated LV Dysfunction,Age 65Female genderLarge infarctionAnterior infarctionPrior infarctionDMPrior HTN,Post-mortem study

2、 of Shock hearts,At least 40%of the myocardium infarcted in the aggregate(old and new injury)80%have significant LAD disease2/3 have severe 3Vdz,Outcomes of Cardiogenic Shock,Historic mortality 60-80%More recently reported mortality numbers67%in the SHOCK trial registry56%in GUSTO-I(v.s.3%in Pts.wit

3、hout shock),Outcomes of Cardiogenic Shock,The ST pattern in Cardiogenic shock:15-30%Non-ST elevation MIOlderMortality:77%70-85%ST elevations MI/New LBBBMortality:53-63%,SHOCK registry findings on this point,Outcomes of Cardiogenic Shock,The SHOCK registrySimilar mortality in the two groups62.5%in no

4、n-ST elevation60.4%with ST elevation,Pathophysiology of Shock,Effect of HypotensionFlow in normal coronary:Regulated by microvascular resistanceCoronary flow may be preserved at AO pressures as low as 50 mm HgIn coronary vessel with critical stenosis:Vasodilator reserve of microvascular bed is exhau

5、stedDecrease in AO pressure=Coronary hypoperfusion,Pathophysiology of Shock,Effect of Hypotension(continued)Normal heart extracts 65%of the O2 present in the blood Little room for augmentation of O2 extraction,Pathophysiology of Shock,Effect of:Elevated LVEDP on coronary flow,LVEDP(mm Hg),Pathophysi

6、ology of Shock,Hypotension+LVEDP and critical stenosis Myocardial Hypoperfusion LV dysfunction Systemic lactic acidosis Impairment of non-ischemic myocardium worsening hypotension.,Schematic,LVEDP elevationHypotensionDecreased coronary perfusionIschemiaFurther myocardial dysfunctionNeurohormonal act

7、ivation VasoconstrictionEndorgan hypoperfusion,Medical Stabilization of Shock Pts.,Figure out the volume status,Swan if in doubtAir wayJudicious afterload reductionMaintain AV synchronyDont tolerate AfibDual chamber pacing if A-V block presentCorrect Acid-Base disturbancesMaintain BP(IABP and/or Pre

8、ssors).,Physiologic Effect of IABP in-vivo,Decreased afterload LV O2 consumption Williams,et.al.,Circulation 1982Kern,et.al.,Circulation 1993Coronary blood flow velocity was measured using doppler-wire in nine patients with critical stenotic lesions.Peak diastolic coronary flow velocity beyond the s

9、tenosis was unaffected by intra-aortic balloon pumping.There was unequivocal IABP-mediated augmentation of both proximal and distal coronary blood flow velocities post PTCA.,Physiologic Effect of IABP in-vivo,Fuchs,et.al.,Circulation,1983Great cardiac vein flow was measured in seven patients receivi

10、ng maximal drug therapy and requiring balloon pumping for unstable angina.All patients had greater than 90%stenosis of the proximal LAD coronary artery.Increased great cardiac vein flow correlated with increased mean aortic diastolic pressure across changes in balloon volumes(off,20 cc,30 cc,and 40

11、cc)and changes in assist ratio(off,1:4,1:2,and 1:1)(p=.02).,Physiologic Effect of IABP in-vivo,Thus balloon pumping increased flow to a bed fed by the critical stenosis,or collateral vessels,IABP in Acute MI,JACC 1985,IABP in Acute MI,Pre-thrombolytic eraNo Lytics,ASA,or Lopressor20 patients with Ac

12、ute MI and“extensive myocardium at risk per baseline Thalium”were Randomized.Pt.s in Shock were excluded,Std.Rx:O2,MSo4,Lido,Heparin,Std Rx+IABP Plus IV NTG,IABP in Acute MI,Patients had repeat Thalium scan on Day-4No differences were observed between the two groups regarding:-Thalium defect score c

13、omparing days 1 and 4-The ejection fraction comparing days 1 and 4=“Unlikely that a mortality benefit is conferred by the IABP/NTG combination”,Utility of IABP in Shock Pts.,Observed clinical benefits:Improved acid-base statusImproved urine outputImproved mentationImproved overall hemodynamics,All t

14、his,however,does not add up to improved survival without Flow Restoration,Thrombolysis in Cardiogenic Shock,Rates of Reperfusion Lower,andRates of Reocclusion HigherThan in non-shock ptsPossible Reason:Diffusion of thrombolytic agent into the thrombus may be PRESSURE DEPENDENT.,BP Effect on efficacy

15、 of lytics in Shock,Dog dataLAD occlusion by thrombusHypotension induced by phlebotomyPrewittJACC 1994;23:784,Any Randomized Trials ofThrombolysis in Cardiogenic Shock?,Most thrombolytic trials specifically excluded patients in cardiogenic shockThe only large placebo-controlled thrombolytic study sp

16、ecifically examining Pts.presenting with shock was GISSI-1Streptokinase=No Benefit,Combined IABP and Thrombolysis,GUSTO-I:IABP in 62 of the 310 lytic Rxd Pts.in shock,Observational Data:,Combined IABP and Thrombolysis,Kovack,et.al.,JACC 1997Stomel,et.al.,Chest 1994Two retrospective observational ser

17、ies from community hospitals:Improved survival from combination Rx.,Combined IABP and Thrombolysis,Observational Data from SHOCK Registery:,Combined IABP and Thrombolysis-Barron,et.al.,AHJ June 2001-National Registry of MI-2,Data base-21,178 pts.Presenting with or developing post-MI shock-32%Receive

18、d IABP,P0.001,P=NS,TT,TT,IABP,PPTCA,PPTCA,IABP,The younger pts.,twice aslikely to get TT=Selection Bias,Combined IABP and Thrombolysis,Accompanying Editorial by Magnus Ohman,and Judith Hochman:“Although,there is a wealth of physiologic and outcomes data to support the use of early IABP therapy in ca

19、rdiogenic shock(in conjunction with lytics),randomized trials are clearly needed.”,Combined IABP and Thrombolysis,The only randomized trial on the subject:Thrombolysis and Counterpusion to Improve Cardiogenic Shock Survival(TACTICS):Results of a Prospective Randomized Trial.Magnus Ohman,et.al.,Circu

20、lation Oct.2000 Supp.Abstract,TACTICS,ST elevation MI patients,presenting within 12 hours of Sx,and Cardiogenic shock57 Patients were randomized,ThrombolyticTherapy alone,ThrombolyticTherapy+IABP,TACTICS,The primary endpoint of 6 month mortality was not statistically significant,P=0.3Subgroup analys

21、is:For KILLIP classes III and IV,P=0.07,PATIENT IS IN SHOCK w/ST elevations,and 12 hrs Sx onset,IABPPressors,May increase the efficacy of Lytics,Administration of Lytics should not be delayed in anticipation of placement of IABPdespite lack of randomized data proving efficay.,If EARLY REVASCULARIZAT

22、ION is not to be pursued:,SHOCK Trial,Whether EARLY REVASCULARIZATION improves survival among patients with cardiogenic shock?,SHOCK Trial,302 Pts.with ST elevation(or new LBBB)and cardiogenic shock,Immediate Revascularization(CABG/PTCA),Late revascularization(if indicated)deferred for at least 54 h

23、ours,Within 36 hrs.of MI onset,Within 12 hrs.of Shock onset,SHOCK Trial:Primary end point,30 days mortality,Diff.=9%P=0.11,47%,56%,Mortality,Diff.=13%P=0.027,50%,63%,52.4%,66.4%,Diff.=14%P0.02,Revasc.,Med Rx,SHOCK TrialWhy wasnt the Primary end-point met?,Low mortality in the initial medical mgt gp.

24、High rates of IABP use,86%TT use,63%Delayed revasculariztion,21%Median of 104 hrspost randomization,30 days mortality,47%,56%,SHOCK Trial:Subgroup analysis,Age less than 75,Revasc.,Med Rx,P=0.02CI1.0,P=0.002CI1.0,Mortality,45%,65%,41%,56%,66.7%,48.4%,P0.02CI1.0,SHOCK Trial:What to do with Pt.s older

25、 than 75,Total no.of Pt.s older than 75 y.o.=56(/302)The early revascularization groups had worse outcome at:30 days(CI 1.0)6 months(CI 1.0)12 months,no difference in outcome,What to do with Pt.s older than 75,SHOCK Registry results is in contrast to the SHOCK Trial findings in this subgroup.Those o

26、lder than 75 y.o.,selected to undergo ERV had a survival advantage.Case by case assessment in this population,and not across the board exclusion is called for.,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,SHOCK Trial:,Stent Placement,35.7%,52.3%,Role of IIb/IIIa inhibitors in Cardioge

27、nic Shock,Retrospective subgroup analysis from the PURSUIT trialHassade,et.al.,JACC,2000 Randomization to eptifibatide did not affect the incidence of shockPatients randomized to eptifibatide who developed shock had a significantly reduced incidence of death at 30 daysA possible mechanism of benefit

28、 is relief of microvascular obstruction,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Long-Term Mortality Benefit With the Combination of Stents and Abciximab for Cardiogenic Shock Complicating Acute Myocardial InfarctionCoronary Artery DiseaseChan,Albert W.MD,MS;Chew,Derek P.MBBS;Bhat

29、t,Deepak L.MD;Moliterno,David J.MD;Topol,Eric J.MD;Ellis,Stephen G.MDAJC Jan.15,2002,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Single center,non-randomizedData collected:Jan.1993 and June 2000 Thirty month follow-up available,96 Pt.s w/Cardiogenic Shock,Stent+ReoproN=27,Stent OnlyN

30、=14,PTCA+ReoproN=18,PTCA OnlyN=37,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Thirty day Mortality Rates(%),Stent+Reopro,Stent Only,PTCA+Reopro,PTCA Only,Absence of Stent use:HR 2.39,95%CI 1.22 to 4.67,p=0.01,Absence of Abciximab use:HR 1.95,95%CI 1.03 to 3.71,p=0.04,On Univariate an

31、alysis:,EF=30%HR 3.44,95%CI 1.35 to 8.78,p=0.01,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Use of Stents29%Absolute mortality reduction1 additional life saved for each 3-4 treated Patients.,Abciximab+Stenting10%Absolute mortality reduction 1 additional life saved for each10 patients

32、 treated.,At 30 months,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Results of Primary Percutaneous Transluminal Coronary Angioplasty Plus Abciximab With or Without Stenting for Acute Myocardial Infarction Complicated by Cardiogenic ShockCoronary Artery DiseaseGiri,Satyendra MD,MPH,MR

33、CP;Mitchel,Joseph DO;Azar,Rabih R.MD,MSc;Kiernan,Francis J.MD;Fram,Daniel B.MD;McKay,Raymond G.MD;Mennett,Roger MSc;Clive,Jonathan PhD;Hirst,Jeffrey A.MD,MSAJC,15 January 2002.,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,This was a nonrandomized,prospective observational study.113(13

34、.9%)were diagnosed with cardiogenic shock from 8/95 to 8/99.,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,No Reopro,With Reopro,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Multivariate Analysis,Role of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock,Speculation:Gre

35、ater use of Abxicimab,and Stents in the SHOCK Trial may well have resulted in a positive primary endpoint.The age cutoff of 75 may or may not have retained its significance vis-vis increased mortality.,Reversal of Cardiogenic Shock by Percutaneous Left Atrial-to-Femoral Arterial Bypass Assistance,Ho

36、lger,et.al,Circulation.2001;104:2917.VADs were implanted in 18 consecutive patients who had cardiogenic shock after myocardial infarctionA 21F venous cannula into the left atrium by transseptal puncture using TEEPts served as their own controlsAll hemodynamic parameters showed significant improvemen

37、t“The influence of this device on long-term prognosis warrants further investigation.”,Take Home Points,Combining Reopro with Stenting is likely to enhance the benefit of early revascularization.IABP helpful in stabilizing the Pt.Mitigates clinical signs of SHOCKMay improve outcome with concurrent L

38、yticsNo definitive evidence(randomized trials)showing improved outcomes with IABP/Lytic combinaiton.,Take Home Points,Nothing magical about the age cut off of 75,case by case assessment in this population is called for.If pt.is not a candidate for early revascularization,but is within12 hrs.of MI onset,administration of lytics(subject to risk-benefit assessment,age,grafts,)should not be delayed in anticipation of placement of IABP.,