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