13/12/15. Diagnóstico, identificación y selección de pacientes con shock cardiogénico susceptibles de tratamiento avanzado. De Que Estamos Hablando?

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1 Diagnóstico, identificación y selección de pacientes con shock cardiogénico susceptibles de tratamiento avanzado Barcelona, 11 de diciembre 2015 Alessandro Sionis Unidad de Cuidados Intensivos Cardiolgicos Hospital de la Santa Creu i Sant Pau Barcelona Potenciales conflictos de presentación: interés en relación con esta - Conferencias: Cardiorentis,Novartis, Orion-Pharma - Ensayos clínicos: Cardiorentis, Novartis, Orion-Pharma - Becas: Novartis 2 De Que Estamos Hablando? Disfunción miocárdica que re su lta en la incapacidad de l corazón para mantener un volumen latido adec uado a pesar de una precarga normal o elevada Hipote nsión arte ria l persistente (> 30 min) (PAS < 90 mmhg) o necesidad de fármacos para mantener PAS > 90 mmhg Congestión pulmonar (crepitantes, R3, Rx tórax) Signos de hipoperfusión tisular conalmenos uno de los siguientes: (i) Alteración del estado mental (ii) Frialdadde extremidades (iii) Oliguria (< 30 ml/h) (iv) Lactato> 2 mmol/l 3 1

2 Clinical Presentation AHF EHS-HF II Nieminen M. Eur Heart J. 2006;27(22): Clinical Presentation AHF EHS-HF II Nieminen M. Eur Heart J. 2006;27(22): Cardiogenic Shock: Etiology STEMI RV LV NSTEMI Mechanical complications 6 2

3 In-hospital Mortality USIK 1995, USIC 2000, FAST-MI France National Registry Deathat 30 days(%) Shock No Shock 63 8,7 4, Aissaoui et a l. Eu r Heart J 2012;33:2535 The Shock Trial: a Revolution Mortality in the SHOCK Trial (n = 302) 53.3 % 66.4 % p < Hochman JS. NEJM 1999; 341:625 8 In-hospital Mortality USIK 1995, USIC 2000, FAST-MI France National Registry Deathat 30 days(%) Shock No Shock ,7 4,2 3, Aissaoui et a l. Eu r Heart J 2012;33:2535 3

4 In-hospital Mortality USIK 1995, USIC 2000, FAST-MI and IABP-II Deathat 30 days(%) Shock No Shock ,7 4,2 3, Aissaoui et a l. Eu r Heart J 2012;33: Thiele H. NEJM 2012; 367: Temporal Trends in CS Incidence Swiss ICU Registry with 23,696 CS patients ( ) Jeger RV et al. Ann Inter Med 2008;149: Data from the Grace Registry ( ) Incidence according to type of ACS Awad H et al. Am Heart J 2012;163:

5 Cardiogenic Shock: Etiology Pneumothorax Pulmonary embolism Peric ardial Valv ular Myocarditis STEMI RV LV Arrhythmias Aortic dissection NSTEMI Mechanical complications Cardiomyopathies 13 CardShock Study: Etiology 220 patients with CS ACS 81% non-acs 19% STEMI 6 8 % NSTEMI 13% Me chanical complications 9% Se ve re low-output failure 10% Othe r 9% Ischemic CMP Dilated CMP... Valvular cause 5% Takotsubo 2 % Myocarditis 2 % Harjola V-P et al. Eu r J Heart Fail 2015;17: CardShock study: Mortality Harjola V-P et al. Eu r J Heart Fail 2015;17:

6 Survival CS Patients Treated With ECMO According to Shock Aetiology Kagawa E et al. ESC Data from the Grace Registry ( ) Onset of Cardiogenic Shock Highest risk subgroups: Older Female Diabetic Chronic heart failure STEMI Cardiac arrest 8.3% of ACS patients develop CS Vast majority develop CS during hospitalisation (71.5%)? Awad H et al. Am Heart J 2012;163: Jeger RV et al. Ann Inter Med 2008;149: Identifying Patients at Risk ALKK PCI Registry n = 9422 pts 1333 (14.2%) CS Influence of symptoms onset to hospital admission time In-hospital Mo rtal i ty ,9 p < ,7 44,9 0-3 h 3-6 h 6-12 h h Lindholm MG. Eu r Heart Journal2003; 24:

7 Identifying Patients at Risk ALKK PCI Registry n = 9422 pts 1333 (14.2%) CS In-hospital mortality related to culprit vessel In-hospital Mo rtal i ty ,3 59,3 45,7 46,2 38,6 LMS CABG CX LAD RCA Lindholm MG. Eu r Heart Journal2003; 24: Identifying Patients at Risk ALKK PCI Registry n = 9422 pts 1333 (14.2%) CS Postprocedural TIMI flow grade and mortality In-hospital Mortality ,2 66,1 37,4 TIMI 3 TIMI 2 TIMI 0/1 Lindholm MG. Eur Heart Journal 2003; 24: Identifying Patients at Risk Age > 75, LMS disease, LVEF <30% and postprocedural TIMI flow grade <3 1-y survival w/o urgent heart trasplantation Survival without need for UHT 83 % 19 % 6 % Time since admission (days) Garcia A. Am J Cardiol 2009;103(8):

8 13/12/15 RV Dysfunction RV dysfunction may cause or contribute to CS In-hospital events in patients with predominant LV or RV CS Jacobs AK. J Am Coll Cardiol 2003;41: RV Matters RV injury not limited to inferior STEMI RV involvement 33% in inferior MI RV involvement 12% in non-inferior MI Masci PG. Circulation 2010;122(14): RV: Not Only The Heart Pulmonary congestion RV ischaemia LV ischaemia RV volume overload Tricuspid regurgitation Ventricular dipendence CO SVR Right sided Filling pressures Venous congestion Renal interstitial pressure Organ perfusion Neurohormonal activation intra-abdominal pressure 24 8

9 Microcirculation Ultimate therapeutic goal in CS is to restore microcirculatory function (adequate oxygen supply to sustain cellular function) Active recruitment of microcirculation is essential Orthogonal polarisation spectral (OPS) imaging allows direct visualization of sublingual microcirculation Ince C. Crit Care Med 1999; 27: Microcirculation Microcirculatory shutdown Before and after nitroglycerin Increased oxygen consumption and impaired oxygen delivery and extraction due to microcirculatory shutdown and shunting Orthogonal polarisation spectral imaging (OPS) During sepsis (and CS) microvasculature is the first to go and the last to recover 26 Spronk PE. Lancet 2001; 360: Microcirculation Sublingual perfused capillary density measured with sidestream dark-field imaging den Uil CA. Eu r Heart Jour 2010;31:

10 Microcirculation den Uil CA. Eu r Heart Jour 2010;31: Microcirculation Predictors of 30-day mortality Survival stratified according to quartile of baseline sublingual PCD den Uil CA. Eu r Heart Jour 2010;31: IABP Shock Trial APACHE II Score and Mortality p< ProndzinskyR et al. Crit Care Med 2010;38:

11 IABP Shock Trial BNP and Mortality p=ns 31 ProndzinskyR et al. Crit Care Med 2010;38: Biomarkers: Natriuretic Peptides Survival according to NT-proBNP JaraiR. et al. Crit Care Med 2009;37: Biomarkers: Lactate Admission lactate and 30-day mortality ( ) Vermeulen et a l. CriticalCare2010;14:R

12 Biomarkers: Lactate 30-day survival after PCI according to lactate levels (>1,8 mmol/l) Vermeulen et a l. CriticalCare2010;14:R Biomarkers: Adrenomedulin AUC for 90-day mortality for lactate and ADM Lactate ADM 0,85 0,8 AUC 0,75 0,7 0,65 0,6 0h 12h 24h 48h 72h 96h 5-10 days Time from baseline Tolppanen H, Rivas-Lasarte M et al. Unpublished data 35 Biomarkers: Adrenomedulin 90-day survival curves for lactate and ADM Tolppanen H, Rivas-Lasarte M et al. Unpublished data 36 12

13 IABP Shock Trial CI and Mortality p=ns 37 ProndzinskyR et al. Crit Care Med 2010; 38: Cardiac Power Output (CPO) and CP Index (CPI) (W) = MAP x CO 0.60 (0.44, 0.83) P<0.002 Couples Pressure (MAP) and Flow (CO) = Cardiac Pumping Cutoff 0.53 W (PPV 56%; NPV 78%). ) Fincke R et al. J Am CollCardiol2004;44: Predictors of In-Hospital Mortality Harjola V-P et al. Eu r J Heart Fail 2015;17:

14 CardShock Risk Score Harjola V-P et al. Eu r J Heart Fail 2015;17: Performance compared to other scores in derivation and validation cohorts Harjola V-P et al. Eu r J Heart Fail 2015;17: Recovery of cardiac function Patient unstable LV AD / ECMO Medical tx Inotr opic suppor t Vasopressor support Fluids Ventilatory support IABP? Revascularization No recovery of cardiac function Patient stable Weaning Weaning Assess neurological & end-or gan dysfunction Standard tx Impaired Weaning Normal Consider surgical LV AD / BiVAD Age, comorbidities? Destination tx Age, comorbidities? Heart tr asplantation Thiele et al. EAPCI Textbook 2012; Chapter

15 13/12/15 Gaps In Knowledge Definition of pre-shock Definition of refractory shock Best approach to MVD (CVLPRIT-SHOCK ongoing) Myocardial protection strategies New biomarkers for early diagnosis of end-organ damage and risk stratification New pharmacological therapies Treatment of SIRS Equipoise in access to best treatment 43 Equipoise in Access to Treatment in CS 44 Necesitamos Un Consenso Sobre Redes de Atención al Shock Cardiogénico! 45 15

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