CARDIOGENIC CARDIOGENIC SHOCKSHOCK

Antonio Antonio PesentiPesenti

Università degli Studi di Milano BicoccaUniversità degli Studi di Milano Bicocca

Azienda Ospedaliera San Gerardo Azienda Ospedaliera San Gerardo –– Monza (MI)Monza (MI)

Primary myocardial dysfunctionresulting in the inability of the heart to mantain an adeuqte

cardiac output (CO) withsubsequent compromising of

metabolic requirements

From: Civetta et al (eds) Critical Care

DEFINITION (1)

• Decreased cardiac output

• Evidence of tissue hypoxia

• Adequate intravascular volume

DEFINITION (2)

• Reduced CI ( < 2.2 l/min/ m2)

• Sustained hypotension ( BP < 90 mmHG or drop > 30 mmHG for > 30 min)

• WP > 15 mmHg

DEFINITION (3)

• Poor tissue perfusion ( cold clammy skin, altered sensorium, oligo-anuria)

• Hypotension

• Jugular vein fillings, rales

CARDIOGENIC SHOCKClinical Recognition

• In the SHOCK trial: 64% of pts :

• Hypotension; • Ineffective CO ( tachycardia, altered

mentation, oliguria , cold periphery• Pulmonary congestion

Menon V, et al. J Am Coll Cardiol 2000;36:1071–6.

CARDIOGENIC SHOCKClinical Recognition

• In the SHOCK trial: 28% of pts :

• Hypotension• Hypoperfusion• No pulmonary congestion ( silent lung)• WP 21.5 + 6.7 mmHG

Menon V, et al. J Am Coll Cardiol 2000;36:1071–6.

GUSTO I study:30 days mortality model

importance of subjective signs• Dying OR = 1.68

• Dying OR = 1.68

• Dying OR = 2.25

• Altered sensorium

• Cold Clammy Skin

• Oliguria

Independently of objective hemodynamicsFrom Hasdai D, et al. Cardiogenic shock complicating acute myocardial infarction: predictors of death. Am Heart J 1999;138:21–31.

CausesCauses (1)(1)SystolicSystolic dysfunctiondysfunction ((decreaseddecreased contractilitycontractility):):

IschemiaIschemia//MyocardialMyocardial InfarctionInfarctionGlobal hypoxemiaGlobal hypoxemiaMyocarditis (viral, autoimmune, Myocarditis (viral, autoimmune, parasiticparasitic))CardiomyopathiesCardiomyopathies ((hypertrophichypertrophic, , amyloidamyloid))MyocardialMyocardial depressantdepressant drugsdrugs ((egeg, , betabeta--blockersblockers, , calciumcalcium

channelchannel blockersblockers, , antiarrhythmicsantiarrhythmics, , propofolpropofol, , anthracyclineanthracycline) ) MyocardialMyocardial contusioncontusionIntrinsic Depression (Intrinsic Depression (egeg, , hypoxiahypoxia, , acidosisacidosis, , hypocalcemiahypocalcemia, ,

hypophosphatemiahypophosphatemia))

CausesCauses (2)(2)

DiastolicDiastolic dysfunctiondysfunction(increased myocardial (increased myocardial stiffnessstiffness))

IschemiaIschemiaVentricular hypertrophy Ventricular hypertrophy Restrictive cardiomyopathy Restrictive cardiomyopathy Consequence of prolonged hypovolemic or septic shock Consequence of prolonged hypovolemic or septic shock Ventricular interdependence Ventricular interdependence External External compressioncompression byby pericardialpericardial tamponadetamponade

CausesCauses (3)(3)

GreatlyGreatly increasedincreased afterloadafterload

AorticAortic stenosisstenosisHypertrophic cardiomyopathy Hypertrophic cardiomyopathy Dynamic aortic Dynamic aortic outflowoutflow tracttract obstructionobstructionCoarctationCoarctation of the aorta of the aorta MalignantMalignant hypertensionhypertension

CausesCauses (4)(4)

ValvularValvular or or structuralstructural abnormalityabnormality

MitralMitral stenosisstenosisEndocarditis Endocarditis Mitral aortic regurgitation Mitral aortic regurgitation Obstruction due Obstruction due toto atrialatrial myxomamyxoma or or thrombusthrombusPapillaryPapillary musclemuscle dysfunctiondysfunction or or ruptureruptureRupturedRuptured septumseptum or or freefree wallwallArrhythmiasArrhythmias

MainMain CauseCause

MiocardialMiocardial InfarctionInfarction (MI)(MI)Cardiogenic Shock Complicates 4.2Cardiogenic Shock Complicates 4.2--7.2 % of the MIs7.2 % of the MIs

Leading cause of death (Leading cause of death (mortalitymortality rate rate ≈≈ 50%)50%)

Usually develops for losses of tissue mass Usually develops for losses of tissue mass greatergreater thanthan 40 %40 %

(N Engl J Med 1999;340:1162-8.)

Ann Intern Med. 1999;131:47-59.

Loss of myocardial contractility

↑ HR↑ Inotropism ↑ Arterial tone ↑ Venous tone

↓ CO ↓ Blood pressure

↑ Adrenergic response

↑ Myocardial VO2 ↑ Afterload

Worsening in myocardial ischemia

↑ Preload

↑ Ventricular ∅↓ Myocardial perfusion

Normal

Depressedcontractility

PreloadPreload doesdoes notnot help…help…10

8

Card

iac

Out

put

(l/m

in)

6

4

2

5 110 5 20 25 30 35Wedge Pressure (mmHg)

In the In the lungslungs

↓ Splancnic perfusion

H2O retention

↑ Preload ↓ Diastolic Function

↑ Atrial pressure

Pulmonary vasculature congestion

Worsening of hypoxaemia

Challenging the paradigm

• LV EF approx 30%• Average SVR not elevated ( wide range)• SIRS obviuos• Survivors class I CHF status

From the SHOCK study

Influence of inflammatory response

FromFrom: : CirculationCirculation 2003; 107: 29982003; 107: 2998--30023002

RoleRole of of systemicsystemic inflammationinflammation

•• A A substantialsubstantial numbernumber of of patientspatients diedie withwitha a normalizednormalized CI in CI in absenceabsence of of obviousobviousinfectioninfection (22.5%)(22.5%)

•• ReleaseRelease of of mediatorsmediators secundarysecundary toto gutguthypoperfusionhypoperfusion? ?

ChestChest 2003, 124:18852003, 124:1885--18911891

LeftLeft ventricleventricle alwaysalways guiltyguilty??

SHOCK SHOCK RegistryRegistry::

•• In 49 of 993 In 49 of 993 patientspatients (5%) the shock (5%) the shock waswascausedcaused byby rightright heartheart infarctioninfarction

•• MortalityMortality notnot differentdifferent in the in the rightright vsvs leftleftventricularventricular shockshock

J J AmAm CollColl CardiolCardiol 2003, 341:12732003, 341:1273--7979

CausesCauses of RV of RV failurefailure

RightRight heartheart infarctioninfarction

Acute Cor Acute Cor PulmonalePulmonaleMassiveMassive PulmonaryPulmonary embolismembolismAcute Respiratory Distress Acute Respiratory Distress SyndromeSyndrome

The RV The RV failurefailureLoss of myocardial contractility

↓ CO ↓ PAP↑ RV Volume

↑ RV Pressure

Tricuspid insufficency↓ LV preload

Venous district and splanchniccongestion

Hypoxaemia

↓ WP !WP !

IntInt Care Care MedMed 2004, 30:1852004, 30:185--9696

HemodynamicHemodynamic patternspatterns duringduring shockshock

BPBP HRHR COCO CVPCVP WPWP

HypovolemicHypovolemic shockshock ↓↓ ↑↑ ↓↓ ↓↓

LeftLeft VentricularVentricular MIMI ↓↓ ↑↑ ↓↓ ↓↓ Or Or NlNl ↑↑

RightRight VentricularVentricular MIMI ↓↓ ↑↑ ↓↓ ↑↑ ↓↓ Or Or NlNl

ExtracardiacExtracardiac ObstructiveObstructivePericardialPericardial TamponadeTamponade ↓↓ ↑↑ ↓↓ ↑↑ EqualizedEqualized

MassiveMassive PumonaryPumonary EmbolismEmbolism ↓↓ ↑↑ ↓↓ ↑↑ Or Or NlNl ↓↓ Or Or NlNl

↓↓ Or Or NlNl

↓↓

CardiogenicCardiogenic shockshock

SepticSeptic//AnaphilacticAnaphilactic shockshock ↓↓ ↑↑ ↑↑ ↓↓ Or Or NlNl

CARDIOGENIC SHOCKTherapy

• Immediate resuscitation

• Early definition of coronary anatomy

• Early revascularization

CARDIOGENIC SHOCKImmediate resuscitation

• Pressure: dopamine noradrenaline dobutamine• Monitor ECG, defibrillators and drugs available

( 33% of SHOCK trial had CPR, VT, or VF)• Oxygen, CPAP, CPPV• Aspirin, heparin• Fibrinolitics if PCI > 90-120 min• IABP

CARDIOGENIC SHOCKEarly definition of coronary anatomy

Circulation 2003: 107: 2998

Circulation 2003: 107: 2998

CARDIOGENIC SHOCKEarly revascularization

Intraaortic Balloon Counterpulsation

BMJ 2003;326:1450-1452

Intraaortic Balloon Counterpulsation

BMJ 2003;326:1450-1452

Intraaortic Balloon Counterpulsation

BMJ 2003;326:1450-1452

Mortality rate after MI

Better drugs ?(N Engl J Med 1999;340:1162-8.)

Patients with cardiogenic shock complicating MI

Medical Therapy

- Thrombolitic therapy- Intraaortic balloon

counterpulsation

Revasculatization

- Angioplasty/Bypass surgery- Intraaortic balloon

counterpulsation

ConclusionsConclusionsAt 30 days there was no significant overall benefit of early revascularization for patients with myocardialinfarction who had cardiogenic shock due to leftventricular dysfunction. However, early revascularizationresulted in lower mortality from all causes at six months.

The The currentcurrent strategystrategy

Cardiogenic shock : commonest cause of death in AMI. -thrombolysis can be attempted with inotropic support or augmentation of bloodpressure with the intra-aortic balloon pump- greatest mortality benefit seen afterurgent coronary angiography and revascularisation

BMJ 2003;326:1450-1452

CARDIOGENIC SHOCK

• VAD• LVAD• ECMO• Et al……

Rossi F et al J.Thorac Cardiovasc Surg 100:914:1990

Healing the heart with ventricular assist devices therapy

• Reversal of left ventricular remodeling: reduction of LV size, improved contractility, regression of myocyte hypertrophy

• Molecular remodeling: apoptosis regulation, improved calcium exchange