Revascularisation strategies

Revascularization Strategies in Management of Cardiogenic shock

Prof. Christian JM Vrints

ESC 2014 Revasc guidelines: management of patients with acute heart failure in the setting of ACS

S Windecker , P Kolh et al. Eur Heart J (2014) 35, 2541–2619

The SHOCK Trial has been the most important study for management guidelines in patients with cardiogenic shock

JS Hochman et al. N Engl J Med 1999;341:625-34

Early Revascularization and 1 Year Survival-SHOCK trial

4437 34

5450 47

30 days 6 months 1 year0

10

20

30

40

50

60

Survival %

Medical therapy

Revascularizationp=0.03p=0.11 p=0.03

• 13% absolute increase in 1 year survival in patients assigned to early revascularization

• number needed to treat of <8 patients to save 1 life

JS Hochman et al. JAMA. 2001;285:190-192

SHOCK trial: CABG vs. PCI

PCI (%) CABG (%) p-value--------------------------------------------------------------------------Diabetes 26.9 48.9 0.02

LMCA 13.0 41.3 0.001

3 vessel disease 60.3 80.4 0.03

coronary jeopardy score 7.1±3.2 9.9±2.3 0.0001

HD White et al. Circulation. 2005;112:1992-2001.

Decreasing in-hospital mortality with increasing rates of early PCI in patients with cardiogenic shock

STEMI registry Germany

U Zeymer et al. ESC Congress Barcelona 2009

Ten-Year Trends in the Incidence and Treatment ofCardiogenic Shock - AMIS Plus Registry

RV Jeger et al.Ann Intern Med. 2008;149:618-626

SHOCK trial: 81% of the patients with cardiogenic shock have multivessel disease


How to treat:–Culprit vessel PCI?–Multivessel PCI?

• Immediate?• Staged procedure?

–CABG?

What do the guidelines recommend?

• Approximately 50% of STEMI patients have significant multivessel disease. Only the infarct-related artery should be treated during the initial intervention. There is no current evidence to support emergency intervention in non-infarct-related lesions.

• The only exceptions, when multivessel PCI during acute STEMI is justified, are in patients with cardiogenic shock in the presence of multiple, truly critical (≥90% diameter) stenoses or highly unstable lesions (angiographic signs of possible thrombus or lesion disruption), and if there is persistent ischaemia after PCI of the supposed culprit lesion.

G. Steg, S James et al. European Heart Journal (2012) 33, 2569–2619

ESC STEMI Guidelines 2012

SHOCK trial: most patients were treated with single vessel PCI of the culprit lesion


Multivessel disease 81%

PCI of infarct related artery only 87%

Complete revascularization 23%

STEMI with shock: Multivessel PCI

Advantages

• Improves:• Peri-infarct blood flow• Remote ischemia in perfusion

territory non–IRA

Disadvantages

• Clinical storm scenario• Pro-thrombotic

• Pro-inflammatory

• PCI of non critical lesions• Distal embolization• No reflow• More:

• Stents

• Contrast

• Radiation

IschemiaLV

dysfunction

Hypotension

X

STEMI with MVD & cardiogenic shock: culprit or multivessel PCI?

In hospital outcomes shock pts.

1 vesselPCI

Multi-vessel PCI

pvalue

Patients 2654 433

Death 27.8% 36.5% <0.01

Death in lab

2.7% 5.8% 0.25

Stroke 1.5% 2.6% 0.18

Bleeding 12.5% 13.8% 0.44

Renal failure

7.1% 9.7% 0.03

Odds ratios mortalityNational Cardiovascular Data Registry

MA Cavender et al. Am J Cardiol 2009;104: 507-513

Multi- vs. 1-vessel PCI

Outcomes of Culprit Versus Multivessel PCI in Patients With MVD Presenting With STEMI Complicated by Shock

Matthew A. Cavender et al.J INVASIVE CARDIOL 2013;25(5):218-224

Patients undergoing MVPCI for STEMI-related shock are clinically different than those treated with culprit PCI only; however, after risk adjustment both groups have similar short- and long-term outcomes.

199 pts @ Cleveland Clinic 2002-2010

Outcomes of Multivessel PCI in Acute MI & Cardiogenic Shock (EHS-PCI Registry)

T Bauer, U Zeymer et al. Am J Cardiol 2012;109:941–946

determinants for hospital mortality

**

*

336 pts MV-PCI 24%

PPCI in STEMI with Resuscitated Cardiac Arrest, and Cardiogenic Shock

D Mylotte et al. J Am Coll Cardiol Intv 2013;6:115–25

Culprit-only vs. multivessel PCI in cardiogenic shock complicating STEMI

Mortality MACE

JH Yang et al. Crit Care Med 2014; 42:17–25

Culprit or multivessel revascularisation in STEMI with cardiogenic shock

46.8

0.6 0.2 1.6

9.5

35.8

1.2 0.13.2 4.3

MACE before discharge

Death

Non-fatal MI

Non-fatal Stroke

Bleeding

Dialysis

0

10

20

30

40

50

% Events

MV-PCI (n=173) Culprit-PCI (n=562)

German PCI registry (2008-2011)735 patients with STEMI, cardiogenic shock & MVDMultivessel PCI in 23,5%

U Zeymer et al. Eurointervention 2015 In press.

Culprit or multivessel revascularisation in STEMI with cardiogenic shock

Jin Sup Park et al.Heart doi:10.1136/heartjnl-2014-307220. In press.

Korean Acute Myocardial Infarction Registry (2006-2012)510 ptsMultivessel PCI in 24,3%

Conflicting results…

Trial N Mortality multivessel

PCI, %

Mortality culprit lesion only PCI, %

Adjusted odds ratio or hazard ratio

(95% CI)

Webb et al. 74 55 20 2.75 (1.05–7.25)Cavender et al. 3087 36.5 27.8 1.5 (1.22–1.95)Bauer et al. 336 48.8 37.4 1.28 (0.72–2.28)Mylotte et al. 266 20.4 43.9 0.57 (0.38–0.84)Yang et al. 338 35.0 30.6 1.06 (0.61–1.86)Zeymer et al. 735 46.8 35.8 1.5 (1.15–1.84)Park et al. 510 12.9 17.9 0.69 (0.40-1.19)

A RCT is underway!

Treatment Algorithm for Cardiogenic ShockAcute MI & Cardiogenic Shock

Fluids for optimal preload

Vasopressors - Inotropes

Early Revascularization

1 – 2 vessel disease

Moderate 3 vessel disease

Left main disease

Severe 3 vessel disease

PCI infarct related artery CABG

Acute multivessel PCI

Staged multivessel PCI

Staged CABG

MCS

HTX

Weaning+-

Peripheral Perfusion

LV-Dysfunctionsystolic diastolic

Death

Hypoxia

LVEDP Lung edema

Cardiac Output Stroke volume

VasoconstrictionFluid retention

Hypotension

Coronary- perfusion

Acute Myocardial Infarction

Reperfusion:PCI/CABG

Ischemia

Mechanical Support:IABP/LVAD

Inotropes/Vasopressors

Cardiogenic Shock Spiral

Thiele et al. Eur Heart J 2010;31:1828-1835

Progressive LV-Dysfunction

Peripheral Perfusion

LV-Dysfunctionsystolic diastolic

Death

Hypoxia

LVEDP Lung edema

Cardiac Output Stroke volume

VasoconstrictionFluid retention

Hypotension

Coronary- perfusion

SIRS

eNOSiNOS

NO Peroxynitrite

IL-6 TNF-α

SVR Pro-InflammationCatecholamine sensitivity Contractility

Acute Myocardial Infarction

Reperfusion:PCI/CABG

Ischemia

++Mechanical Support:IABP/LVAD

Inotropes/Vasopressors

+

+

Bleeding/Transfusion

Cardiogenic Shock Spiral

Thiele et al. Eur Heart J 2010;31:1828-1835

SIRS: Systemic Inflammatory Response Syndrome

Progressive LV-Dysfunction

• An integrate approach is needed with:– Early revascularization– Inotropic support– Mechanical support eventually as bridge to HTX

• Multidisciplinary collaboration needed by:– Interventional cardiologists– Cardiac surgeons– Intensive acute cardiac care cardiologists– Heart failure cardiologists

Cardiogenic shock remains a major challenge in acute cardiac care

Revascularisation strategies

Healthcare

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