Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to...
Transcript of Cardiogenic Shock: Pharmacological and Mechanical Therapy · IMPRESS trial of ImpellaCompared to...
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
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
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.
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
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.
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.
12/17/16
7
Impella Device
Impella Registry:EarlyImplantationofImpella MayImproveOutcomes
O’Neill.JInt Cardiology,2014.
Impella Registry:EarlyImplantationofImpella MayImproveOutcomes
O’Neill.JInt Cardiology,2014.
12/17/16
8
IMPRESStrialofImpella ComparedtoIABPInCardiogenicShock:NoDifferenceInMortality
Ouweneel.JACC.2016.
MetaAnalysisDemonstratesBetterHemodynamics,IncreasedComplications,SimilarOutcomes
Cheng.Eur HeartJ,2009.
MetaAnalysisDemonstratesBetterHemodynamics,IncreasedComplications,SimilarOutcomes
Cheng.Eur HeartJ,2009.
12/17/16
9
FewDataToEvaluateECMO
Machuca.Circulation,2015.
TheUseOfMCSDevicesHasIncreasedDramatically
Stretch.JACC,2014.
MortalityHasDecreasedForRecipientsofShortTermMechanicalSupport
Stretch.JACC,2014.
ShiftToEarlierUseofPercutaneousDevicesforMCS
Stretch.JACC,2014.
12/17/16
10
ATeamApproachToEvaluationOfTheCandidatesForAdvancedMechanicalSupportIsRecommended• Heartfailure/hearttransplantspecialist• Intensivist• Cardiacsurgeon
PathwaytoDecisionforUseofMCS
Peura Circulation,2012.
ConsiderationsInChoosingMechanicalSupport
Thiele.Eur HeartJ.,2015.