32ν Παλειιήλην Καξδηνινγηθό πλέδξην - άββαην 22αο Οθηωβξίνπ 2011
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How to treat the patient with acute myocardial infarction and…
Καξδηαθή αλεπάξθεηα
Heart failure
Γεώξγηνο Χάραιεο, Επίθνπξνο Καζεγεηήο Καξδηνινγίαο
George Hahalis, Assistant Professor of Cardiology
Ρίνλ, Πάηξα - Rio, Patras
How to treat post-MI heart failure
Outline…
•What do we know (registries-cohort studies)?
•Pharmaco-invasive strategies and treatment for:
•prevention-limitation of MI size
•post-MI therapy of LV dysfunction - mechanical complications
•Guidelines
•How should we treat these patients (case-scenarios)
How to treat post-MI heart failure
Outline…
•What do we know (registries-cohort studies)?
•Pharmaco-invasive strategies and treatment for:
•Prevention-limitation of MI size
•post-MI therapy of LV -mechanical complications
dysfunction
•Guidelines
•How should we treat these patients (case-scenarios)
Heart Failure and Myocardial infarction
i) Timing of development
•Discharge Dx: MI in 1998 (N=898 pts); Follow-up until 2005
(Torabi A. Eur Heart J 2008;29:859)
ii) Causes of death
How to treat the patient with acute myocardial infarction a & heart failure
-9 %
Cath B-blockers
-15 %
HF vs. no HF pts
STEMI NSTEMI UA No HF
& HF & HF & HF
Mortality
In-Hospital
12 % 11 %
3.0 %
17 %
GRACE registry16 166 patients analyzed: 13 707 pts
without prior HF or shock at presentation
Swedish registry1993-2004 trends for a first
episode of HF within 3 years in
175216 pts 35–84 yo & first MI
Decrease of HF risk
by 4%/year
2002-04
1993-95
(Shafazand M. Eur Heart J 2011;13:135) (Steg PG. Circulation 2004;109:494)
How to treat the patient with acute myocardial infarction a & heart failure
TIMI Risk Score in STEMI (but not in Non-STEMI) &
GRACE Score Include Hemodynamic Instability
65-74 years
75 years and older
History of angina, diabetes, or hypertension
•Admission systolic blood pressure <100 mm Hg
•Admission heart rate >100 beat/min
•Admission Killip class II to IV
Admission weight <67 kg
Anterior infarction or LBBB
Time to reperfusion therapy >4 hours among reperfused pts
Older age
•Killip class
•Systolic BP
ST-segment deviation
Cardiac arrest during presentation
Serum creatinine level
Positive initial cardiac biomarkers
•Heart rate
TIMI score
In STEMI
GRACE score
How to treat the patient with acute myocardial infarction a & heart failure
How to treat post-MI heart failure
Outline…
•What do we know (registries-cohort studies)?
•Pharmaco-invasive strategies and treatment for:
•Prevention-limitation of MI size
•post-MI therapy of LV -mechanical complications
dysfunction
•Guidelines
•How should we treat these patients (case-scenarios)
Less Incident Heart Failure by Limiting Total Ischemic Time
EMS Transport
Onset of
symptoms of
STEMI
9-1-1
EMS
Dispatch
EMS on-scene• Encourage 12-lead ECGs.
• Consider prehospital fibrinolytic if
capable and EMS-to-needle within
30 min.
GOALS
PCI
capable
Not PCI
capable
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Inter-
Hospital
Transfer
Golden Hour = first 60 min. Total ischemic time: within 120 min.
Patient EMS Prehospital fibrinolysisEMS-to-needle
within 30 min.
EMS transportEMS-to-balloon within 90 min.
Patient self-transport
Hospital door-to-balloon
within 90 min.
Dispatch
1 min.
5
min.
8
min.
Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December 10, 2007. Available at
http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001. Figure 1.
How to treat the patient with acute myocardial infarction a & heart failure
Conservative Rescue PCI
treatment
12.7 %
(54/424)
-27%
17.8 %
(76/427) P=0.05
Incident heart failure
Rescue PCI vs. Conservative Therapy After Failed Thrombolysis
(Wijeysundera HC Metaanalysis. JACC 2007;49:422)
How to treat the patient with acute myocardial infarction a & heart failure
RR=0.62 (P=NS)
RR=0.61
0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6
Lower Higher
Post-discharge Mortality Risk
PCI vs No Revascularization
CABG vs No revascularization
Heart Failure in Non-STEMI: Post-discharge Mortality
Depending on In-hospital Revascularization Status
(Steg PG . Circulation 2008;118:1163)
How to treat the patient with acute myocardial infarction a & heart failure
ACE-Ihhibitors vs. Placebo After Myocardial Infarction(N=5966 pts in three trials with average follow-up 35 months)
Placebo Yes ACEI Placebo Yes ACEI Placebo ACEI
23 %
29 %-26%
29 %
23 %
-26%29 %
23 %
-26%29 %
Mortality
23 %
-26%29 %
Readmissions for HF
12 %
-27%16%
Reinfarction
10.5%
-20%13 %
(Flather MD, Yusuf S et al. Lancet 2000;355:1575 & Lee VC et al. Ann Intern Med 2004;141:693)
•2 RCT’s (OPTIMAAL-VALIANT)
of ACE-Inhibitors vs ARBs for high-risk post-
MI patients: No differences in all-cause
mortality or HF hospitalization
23 %
How to treat the patient with acute myocardial infarction a & heart failure
Placebo β-blocker Placebo β-blocker Placebo β-blocker Placebo β-blocker
9.0 %-36%
GMP, Metoprolol(9% with HF; 3 mo. FU)
5.7 %
NNT, Timolol(34% with HF;17 mo. FU)
16 %
11 %
-35% -23%
CAPRICORN,
ACEI+Carvedilol (17 mo. FU)
15.3 %
12 %
BHAT, Propranolol
(14% with HF;25 mo. FU)
-25%
Hjalmarson Å, Lancet 1981; ii:823
Norwegian MS Group NEJM 1981;304:801
BHAT Research Group JAMA 1982;247:1707
CAPRICORN, Lancet 2001;357:1385
Eur J Heart Fail 2002;4: 501
Total
mortality
Beta-blockers vs. Placebo Post-MI & Impaired Systolic Function
How to treat the patient with acute myocardial infarction a & heart failure
-15%
Placebo Epleronone Placebo Epleronone
(+ Optimal Medical Treatment: ACEI/ARB - β-Blockers - Revascularization)
26.7 %
30 %
14.4 %
16.7 %
•6 632 patients with AMI (in prior 3-14 days) + LVEF<40% + Heart Failure or DM w/o HF
CV Death-Repeat hospitalization
Mortality
P=0.008
P=0.005-17%
(N Engl J Med 2003;348:1309)
EPHESUS Trial (Epleronone in post-MI Heart Failure)
How to treat the patient with acute myocardial infarction a & heart failure
Clopidogrel: No (n=2525)
Clopidogrel: Yes (n=2525)
Clopidogrel: No (n=3046)
Clopidogrel: Yes (n=3046)
9.7%
9.4 %
Patients with heart failure P=0.002
Patients without heart failure P=NS
Heart Failure in STEMI Patients Without PCI:
Increased Mortality in Low Clopidogrel Use
(Bonde L. JACC 2010;55:1300)
32 %
28 %
Pro
pensity m
atc
hed c
ohort
s
How to treat the patient with acute myocardial infarction a & heart failure
Randomized to emergency revascularization (n=152, 87% revascularized, 55% with PCI),
or medical stabilization (n=150; 2.7% revascularized); IABP in 86%
Median time to the onset of shock: 5.6 hours; mean EF: 30%;
The SHOCK trial
(Sanborn TA, JACC 2000;36:1123)
Time from MI to 73
randomization < 6 hr
Time from MI to 227
randomization > 6 hr
Subgroup No of pts
0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6
Odds Ratio
50
%
100
%
Conserv group
< 75 years >75 years
Revasc group
P=0.003
6-month mortality
Revascularization
better
Conservative
better
(NEJM 1999)
The SHOCK Registry: Mortality in 884 patients
•No thrombolysis, no IABP: 77%
•Thrombolysis: 63%
•Thrombolysis+IABP:47%
How to treat the patient with acute myocardial infarction a & heart failure
should have been excluded
Vasovagal reaction
Pharmacological hypotension
Hypovolemia
Arrhytmias
Tamponade
Electrolyte disturbances
Differential diagnosis of cardiogenic shock
•Extensive LV myocardial damage (78% in the SHOCK registry)
•RV infarction (2.8% in the SHOCK registry)
•Mechanical complications
•Ventricular septal rupture
•Papillary muscle/tip rupture: acute MR
•Free wall rupture-tamponade
(Hochman JS. JACC 2000;36:1063 (3 Suppl A) & STEMI guidelines ESC 2008)
(11% in the
SHOCK registry)
How to treat the patient with acute myocardial infarction a & heart failure
Devices in Cardiogenic Shock
IABP Versus LVAD IABP Versus No-IABP
3 Randomized Trials 11 Non-Randomized Trials
(n= 100) (n=10439)
Bleeding risk
30-days mortality
P<0.05
P=NS
P=NS
Relative Risk
0 10
Favors LVAD Favors IABP
Better Less
Hemodynamice Bleeding
RR=2.35 (1.4-3.9)
Leg ischemia
(+0.05 to +0.15)
-0.5 0 +0.5
Favors IABP Favors Non-IABP
30-day Mortality: Risk difference
No reperfusion(Moulopoulos)
-0.3
-0.2
(-0.5 to -0.1)
(-0.3 to -0.1)Thrombolysis
Primary PCI+0.1
(Sjauw KD. EHJ;2009;30:459)
(Cheng JM. EHJ;2009;30:2102)
How to treat the patient with acute myocardial infarction a & heart failure
How to treat post-MI heart failure
Outline…
•What do we know (registries-cohort studies)?
Which is our armamentarium?
•Pharmaco-invasive strategies and treatment for:
•Prevention-limitation of MI size
•post-MI therapy of LV -mechanical complications
dysfunction
•Guidelines
•How should we treat these patients (case-scenarios)
O2, Diuretics, ACI/ARB, Epleronone
Early revascularization (Killip III,IV)
IABP, ventilatory support (Killip III,IV)
IIb
IIb
IIa
IIa
IIa
I
I
I
Emergent cath (<2h): UA/NSTEMI & Killip II-IV
LVAD (Killip IV)
Dopamine (Killip III,IV)
Dobutamine (Killip III,IV)
Right heart catheterization (Killip III,IV)
ESC Guidelines: Heart failure (2008) & Myocardial Revascularization (2010)
How to treat the patient with acute myocardial infarction a & heart failure
Pharmacological Treatment
Initial dosage(mg)
Target dosage(mg)
•CaptoprilSAVE, ISIS-4, CHINESE 6.25 - 12.5 @ 2h 50X3
•LisinoprilGISSI-3 5 10
•ZofenoprilSMILE 7.5X2 30X2
•RamiprilAIRE 2.5X2 5X2
•TrandolaprilTRACE 0.5 5
•LosartanOPTIMAAL 12.5 50
•ValsartanVALIANT 20 160X2
•EplerononeEPHESUS 25 50
•CarvedilolCAPRICORN 3.125X2 25X2
How to treat the patient with acute myocardial infarction a & heart failure
(STEMI focus update AHA/ACC 2009 & UA/NSTEMI guidelines ESC 2011)
Recommendations Class Level
•Thrombolysed STEMI in nonPCI hospital and Killip II or III:Preparatory antithrombotic (anticoagulant + antiplatelet) regimen before and during
patient transfer to the cath lab
Transfer to a PCI capable facility as soon as possible
IIa B
•Failed or uncertain thrombolysis result:
Rescue PCI immediately
IIa B
•Severe, persisting LV dysfunction > one month post MI:
Cardiac resynchronization therapy + ICD
IIa B
How to treat the patient with acute myocardial infarction a & heart failureHow to treat the patient with acute myocardial infarction a & heart failure
Hemodynamically
remaining
instability
LVAD or BiVAD
Not weaning
No neurological deficit
(Myocardial revascularization guidelines ESC 2010)
Ultra compact mobile ECMO-
Cardiohelp circuit-
23 F(right FV)
17 F (left FA)
17 F
(jugular
vein)
ECMO support
How to treat the patient with acute myocardial infarction a & heart failure
How to treat post-MI heart failure
Outline…
•What do we know (registries-cohort studies)?
Which is our armamentarium?
•Pharmaco-invasive strategies and treatment for:
•Prevention-limitation of MI size
•post-MI therapy of LV -mechanical complications
dysfunction
•Guidelines
•How should we treat these patients (# 6 case-scenarios)
Urgent cath
Stabilized
ACEI/ARB
Oral β-blocker
Epleronone
DAPT *Anticoagulation
Echo
Killip II or III
(or Flush PE)
NSTEMI
ST-Depression
New onset acute HF
cTroponin: +
* Dual antiplatelet therapy
Heart Failure Killip II or III & NSTEMI
Ventouri mask/CPAP, Loop diuretics, Nitrates i.v.
# 1How to treat the patient with acute myocardial infarction a & heart failure
Killip III
NSTEMI
ST-Depression
DAPT
Anticoagulation
Echo (EF=35%)
ACEI
Oral b-blocker
Epleronone
Killip III
NSTEMI
ST-Depression
DAPT
Anticoagulation
Echo (EF=35%)
Killip III
NSTEMI
ST-Depression
DAPT
Anticoagulation
Echo (EF=35%)
Killip III
NSTEMI
ST-Depression
ACEI
Oral b-blocker
Epleronone
DAPT
Anticoagulation
Echo (EF=35%)
Killip III
NSTEMI
ST-Depression
ACEI
Oral b-blocker
Epleronone
DAPT
Anticoagulation
Echo (EF=35%)
Killip III
NSTEMI
ST-Depression
ACEI
Oral b-blocker
Epleronone
DAPT
Anticoagulation
Echo (EF=35%)
Killip III
NSTEMI
ST-Depression
Primary PCI
DAPT *
Anticoagulation
+IABP
Killip II or III
e.g., Anterior STEMI
PCI available
(D2B< 90min)
Heart Failure Killip II or III & STEMI (1)
Intubation/Ventilatory support, Loop diuretics, Nitrates i.v
ACEI/ARB,
Oral β-blocker, Epleronone
RST/ICD ++
* Dual antiplatelet therapy
# 2How to treat the patient with acute myocardial infarction a & heart failure
DAPT
Anticoagulation
Echo (EF=35%)
ACEI
Oral b-blocker
Epleronone
DAPT
Anticoagulation
Echo (EF=35%)
DAPT
Anticoagulation
Echo (EF=35%)
ACEI
Oral b-blocker
Epleronone
DAPT
Anticoagulation
Echo (EF=35%)
ACEI
Oral b-blocker
Epleronone
DAPT
Anticoagulation
Echo (EF=35%)
ACEI
Oral b-blocker
Epleronone
DAPT
Anticoagulation
Echo (EF=35%)
Thrombolysis
DAPT *
Anticoagulation
+IABP
Killip II or III
e.g., Anterior STEMI
PCI NOT available
(D2B > 90min)
Transfer
Secondary PCI
ACEI/ARB, Oral β-blocker, Epleronone
RST +
Heart Failure Killip II or III & STEMI (2)
* Dual antiplatelet therapy
Intubation/Ventilatory support +, Loop diuretics, Nitrates i.v.
# 3How to treat the patient with acute myocardial infarction a & heart failure
Primary PCI better than
Thrombolysis
DAPT
Anticoagulation
Preload increase
Inotropes
Inferior STEMI
Hypotension, no rales,
Increasd JVP
DD: Tamponade,
Pulm Embolism
Predominant RV Infarction
Echo (Rule out mechanical complications)
Intubation/Ventilatory support +, NO Nitrates (!)
# 4
70 year old woman;
Failed primary PCI of the RCA on
18/10/2011;
Death on 19/10/2011
How to treat the patient with acute myocardial infarction a & heart failure
Secondary (rescue)
multivessel
PCI
Transfer
Thrombolysis
DAPT
Anticoagulation
IABP if possible
Cardiogenic
Shock
PCI NOT
Available
Intubation/Ventilatory support, Loop diuretics, Inotropes
Cardiogenic Shock (1)
Echo (Rule out mechanical complications)
ACEI/ARB,
Oral β-blocker,
Epleronone
RST
# 5How to treat the patient with acute myocardial infarction a & heart failure
Cardiogenic Shock (2)
Primary,
multivessel PCI
or emergent CABG
DAPT
Anticoagulation
IABP
Cardiogenic
Shock
PCI
available
Intubation/Ventilatory support, Loop diuretics, Inotropes
Echo (Rule out mechanical complications
ACEI/ARB, Oral β-blockers, Epleronone,
CRT
# 6How to treat the patient with acute myocardial infarction a & heart failure
Mild systolic murmur; Emergent operation;
Death on 19/10/2011
33 year old man, Primary PCI of the LCx on 16/10/2011
How to treat the patient with acute myocardial infarction a & heart failure
Cardiogenic Shock (3)
# 6
to treat the patient with acute myocardial infarction a & heart failure
Thank you for
your attention
Εσταριστώ για
την προσοτή σας
to treat the patient with acute myocardial infarction a & heart failure
Back-up slides
P<0.005
P<0.005
1.0 %
3.0 %
5.0 %
2.0 %
BNP<80 pg/ml(n=1251)
BNP>80 pg/ml(n=1274)
30 days 10 months
Recurrent heart failure
0 2.5 5
Έηε παξαθνινύζεζεο
Mortality(n=609)
BNP in ACS’s, Recurrent Heart Failure & Mortality
(De Lemos JA. NEJM 2001;345:1014) (Omland T. Circulation 2002;106:2913)
Killip I
Killip II
BNP, low
BNP, high
BNP, low
BNP, high
•Centrifugal pump (Vortex CN80; BioMedicus, Medtronic,
Englewood, CA)
•Pressure-controlled biocompatible heparin-coated polypropylene
Oxygenator (Affinity; Omnis AOT GmbH, Bad Oyenhausen,
Germany [membrane surface area of 2.5 m2 and a maximum
blood flow of 7.0 L/min]) and
•Heat exchanger
ECMO support
•ECMO flow gradually increased to 4.5 L/min
•If renal insufficiency present: a hemofiltration unit integrated into
the circuit
•Arterial return cannula (15F to 21F) inserted directly into the
ascending aorta -the femoral artery (percutaneously or through a
6-mm prosthesis) -the subclavian artery
•Venous drainage (21F to 28F) inserted either directly into the RA
or into the femoral vein with placement of the tip just proximal to
the right atrium
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