Primary Angioplasty and Hemodynamic Support in
Cardiogenic Shock
Department of Internal Medicine, College of Medicine, Yonsei University
Hyuck Moon Kwon, M.D.
Epidemiology of Cardiogenic Shock
Occurrence of shock
STEMI Non- STEMI
4.2-7.2%(GUSTO)
2.9%(PURSUIT)
Median time from enrollment to shock
9.6h 76h
Unstableangina
2.1%(PURSUIT)
94h
Hasdai et al. JACC 2000;36:687
Definition of Cardiogenic Shock
SBP < 90mmHg for >30min-1 hr that is :• Unresponsive to fluid administration alone• Secondary to cardiac dysfunction, or• signs of end-organ hypoperfusion, or • CI<2.2L/min/m and PCWP>15-18mmHg.
• SBP increase to>90mmHg within 1 hr after administration of inotrophic agents
• Death within 1 hr of hypotension but met other criteria for cardiogenic shock.
ACC clinical data standard JACC 2001;38:2127
ACC/AHA Guidelines (1999/2000) for PCIin Cardiogenic Shock
• Class I recommendation• Primary PTCA: within 36 hrs of an acute ST
elevation / Q-wave or new LBBB who develop cardiogenic shock are < 75 years old,
• Revascularization (PCI or CABG) within 18 hrs of onset of shock.
J Am Coll Cardiol 1999;34:`904
Predictors of Cardiogenic Shockafter STEMI
• Patient’s age - most important• SBP• HR• Killip Class
- Hasdai et al,Lancet 2000;356:749
Primary Angioplasty in CS
Employed criteria ? GUSTO-1 Selection bias ? SHOCK vs SMASH Randomized controlled study? Time of studies ?
Overall mortality: 44% Successful PCI: 33% Unsuccessful PCI: 81%
• Cardiogenic shock : 7.2% (among 41,021 pts)
• Overall 30-day mortality : 55%
• 30-day mortality of CABG group : 29%
• 30-day mortality of PTCA group : 22%
• Comparison of 1 yr mortality, PTCA vs no PTCA :
the hazard ratio : 0.81(95% CI,0.71-0.94; p<0.005)
•Limitations : not randomized study. Selection bias.
GUSTO-I (Cardiogenic shock subgroup analysis)
SHOCK trial : Randomized and controlled study
Acute Myocardial Infarction
Shock
Randomization
Emergency Revascularization Initial medical Stabilization
IABP/Pharmacological supportPossible prior thrombolysisEmergency earlyPTCA(60%)/CABG(40%)<= 6 hrs
IABP/Pharmacological supportThrombolysis unless absoluteContraindication (63%)Delayed revasc.(25%) >54hr
<= 36hr
<= 12hr
Hochman et al,NEJM 1999;341:625
• Primary end point : 30-day mortality• Secondary end point : 6 mo. mortality
Outcome and Subgroup
30-day mortalityTotalAge<75yrAge>=75yr6-mo. mortalityTotalAge<75yrAge>=75yr
ERV
46.7(152) 41.4(128) 75.0(24)
50.3(151) 44.9(127) 79.2(24)
Medical Therapy
56.0(150)56.8(118)53.1(32)
63.1(149)65.0(117)56.3(32)
Difference
-9.3 -15.4 +21.9
-12.8 -20.1 +22.9
percent(number in subgroup)
Relative risk
0.83 0.73 1.41
0.80 0.70 1.41
P-value
0.110.01
0.0270.003
SHOCK Trial : Mortality among Study Patients
Hochman et al ,NEJM 1999;341:625
PCI in the SHOCK Trial Registry (93-97’, n=884)
Webb J et al, Am. Heart J.2001;141:964-71
In-hospital mortality: 46.4% in PCI (n=276) vs 78.0% in medically (n=499) MI-PCI: Median 8.8hrs, Shock-PCI: 3.3hrs
PCI within 6 hrs of MI 40.2%PCI within 6-12 hrs of MI 50.9%PCI within 12-24 hrs of MI 60.5%PCI within 24hrs of MI 43.9%
Pts with PCI: younger, shock earlier, higher LVEF & CI
Final TIMI flow grade after PCI and in-hospital mortality rates in SHOCK Registry patients with pump(Lt.or Rt.ventricular) failure. (P< 0.001).
( Webb J et al, Am. Heart J.2001;141:964-71)
0
20
40
60
80
100
0 or 1(n=35) 3(n=111)
85.7%
50.0%
In-h
ospi
tal m
orta
lity
(%)
33.3%
2(n=24)Final TIMI Flow Grade
Angiographic success and in-hospital mortality rates in SHOCK Registry patients with pump failure. Success is defined as residual stenosis<50% and final TIMI flow grade of 2 or 3(P< 0.001).
( Webb J et al, Am. Heart J.2001;141:964-71)
0
20
40
60
80
100
Unsuccessful(n=40) Successful(n=119)
82.5%
36.1%
In-h
ospi
tal m
orta
lity
(%)
Region
ANCEuropeABUSAP value
Hospital mortality(%)
58 65 79 39 < 0.0001
ERV(%)
25 31 46 57 <0.0001
Stent use
25 80 53 80 0.0019
GPIIbIIIa Inhibitor 5 15 9 26 0.0005
Global Use of Revascularization for Pts. in Cardiogenic Shock: Global registry of Acute Coronary Events (GRACE, 99-00’, n=535)
ANC: Australia/New Zealand/Canada, AB: Argentina/brazil
Dauerman et al, Am J cardiol 2001;88(suppl 5A)
•The most powerful predictor of in–hospital survival : PCI with stenting(n=535, odds ratio, 5.8 ; 95% confidence interval, 3.3-10.4)
Long-term Results after acute PCI in AMI with shock
12-months survival rate 47% SHOCK trial
60% Ajani et al. AJC 2001;87:633
80% Ammann et al. Int J of cardiology 2002;82:127
Early prediction - ERV with stenting & anti-PLT !!
Beneficial effect of GP IIb/IIIa receptor blockers in patients undergoing primary PCI/Stenting in CS:
1-month mortality (n=74) 19 vs 41%Antoniucci D et al. Am J Cardiol. 2001;88:5A
In hospital mortality (n=323) 26.4 vs 34.4%Moscucci M et al. JACC. 2002;39:330A
Glycoprotein IIb/IIIa inhibitors
Hemodynamic Support in Cardiogenic Shock
IABP in Cardiogenic Shock
• Diastolic inflation - Augmentation of DBP
• Systolic Deflation - Afterload Reduction
• Contraindicated in severe Aortic regurgitation !
-Increases diastolic coronary arterial perfusion
- Reduce LV wall stress- Decrease myocardial oxygen demand- Increase in cardiac output
• IABP as an an adjunctive treatment to revascularization in GUSTO-I trial, a trend towards lower 30-day and 1 -year mortality rates. (Anderson et al. JACC 1997;30:708-715)
(Barron et al,Am heart J 2001;141:933-939)
IABP in Cardiogenic Shock complicating AMI
• SHOCK trial : IABP used in 86%• National Registry of MI-2 IABP in 7268/23180 (31%): Thrombolytic therapy with IABP :49 vs 67 % Primary angioplasty with IABP :47 vs 45 %
Conclusion
• Prevention is the best policy: identification of pre-shock state followed by preventing deterioration into cardiogenic shock.
• Strategy of ERV: PTCA/CABG accompanied with IABP support. for > 75yrs old,invasive strategy on case by case basis.
• TIMI flow after PCI was strongly associated with in-hospital mortality rate.
Thrombolytic therapy
• The outcome of cardiogenic shock is closely linked to the patency of the culprit coronary arteries
• Thrombolytic therapy has decreased the occurrence of shock among patients with persistent STEMI.
• The GUSTO-I : t-PA is more efficacious than streptokinase in preventing shock.
Thrombolysis in cardiogenic shock
• Results have been disappointing• Cause : ? limited efficacy of lytics in the
setting of low perfusion pressure.• GISSI-I Study
Mortality of thrombolysis(streptokinase) group = 69.9% Mortality of. control group = 70.1%
-David Hasdai et al,Lancet 2000;356:753
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