Management of Cardiogenic shock. Prof. Christian JM Vrints

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1 Management of Cardiogenic shock Prof. Christian JM Vrints

2 none conflicts

3 Management of Cardiogenic Shock Incidence and trends Importance of early revascularization Multivessel disease Left main disease

4 Incidence & Causes Cardiogenic Shock NRMI registry Cardiogenic shock occurs in 8.6% of the acute MI patients On admission: 29% During hospitalization: 71% A Babaev et al. JAMA. 2005;294(4): LV dysfunctionµ 78,5 SHOCK trial otherµ 6,7 Pericardial Tamponadeµ 1,4 Right Ventricular Acute Shockµ Mitral 2,8 Regurgitationµ Ventricular 6,9 Septal Defectµ 3,9 JS Hochman et al. N Engl J Med 1999;341:625-34

5 Ten-Year Trends in the Incidence and Treatment of Cardiogenic Shock - AMIS Plus Registry RV Jeger et al. Ann Intern Med. 2008;149:

6 Cardiogenic Shock Spiral Acute Myocardial Infarction LV-Dysfunction systolic diastolic Inotropes/ Vasopressors Cardiac Output Stroke volume LVEDP Lung edema Mechanical Support: IABP/LVAD Reperfusion: PCI/CABG Peripheral Perfusion Vasoconstriction Fluid retention Hypotension Coronaryperfusion Ischemia Hypoxia Progressive LV-Dysfunction Death Thiele et al. Eur Heart J 2010;31:

7 Cardiogenic Shock Spiral Acute Myocardial Infarction LV-Dysfunction systolic diastolic Inotropes/ Vasopressors + + SIRS Cardiac Output Stroke volume LVEDP Lung edema Mechanical Support: IABP/LVAD Reperfusion: PCI/CABG + Bleeding/ Transfusion + enos inos NO Peroxynitrite IL-6 TNF-α Peripheral Perfusion Vasoconstriction Fluid retention Hypotension Coronaryperfusion Ischemia Hypoxia Progressive LV-Dysfunction SVR Pro-Inflammation Catecholamine sensitivity Contractility Death SIRS: Systemic Inflammatory Response Syndrome Thiele et al. Eur Heart J 2010;31:

8 Management of Cardiogenic Shock Incidence and trends Importance of early revascularization Multivessel disease Left main disease

9 What do the guidelines recommend? ESC STEMI Guidelines 2008 Primary PCI Class level Preferred treatment if performed by an experienced team as soon as possible after FMC I A Time from FMC to balloon inflation should be <2 h in any case and <90 min in patients presenting early (e.g.,2 h) with large infarct and low bleeding risk Indicated for patients in shock and those with contraindications to fibrinolytic therapy irrespective of time delay I B I B F Van de Werf et al. Eur Heart J 2008; 29,

10 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

11 Survival % Early Revascularization and 1 Year Survival-SHOCK trial Medical therapy Revascularization p=0.11 p=0.03 p= % absolute increase in 1 year survival in patients assigned to early revascularization number needed to treat of <8 patients to save 1 life days 6 months 1 year JS Hochman et al. JAMA. 2001;285:

12 SHOCK trial: CABG vs. PCI PCI (%) CABG (%) p-value Diabetes LMCA vessel disease coronary jeopardy score 7.1± ± HD White et al. Circulation. 2005;112:

13 SHOCK trial : important limitations! No randomization between PCI or CABG: selection bias undoubtedly influenced results Old fashioned PCI methods: Low use of coronary stents SHOCK: 37% SHOCK registry: 24% Low use of IIb IIIa antagonists: SHOCK: 69% SHOCK registry: 7% No use of bivalirudin or DES No thrombus aspiration

14 Influence of Stenting and IIb/IIIa Inhibition (ACC-NCDR) LW Klein et al. Am J Cardiol 2005;96:35 41

15 Decreasing in-hospital mortality with increasing rates of early PCI in patients with cardiogenic shock STEMI registry Germany % ,2 early PCI 67,7 mortality 56,1 46, ,1 U Zeymer et al. ESC Congress Barcelona 2009

16 What to do in multivessel disease & cardiogenic shock?

17 Many good reasons not to perform urgent CABG in cardiogenic shock STEMI = a clinical storm worst setting for performing a CABG Increased risks for complications: ~prothrombotic & inflammatory milieu in the early phase of acute MI: aggravation of SIRS lesion severity in nonculprit vessels is frequently overestimated ~diffuse coronary vasoconstriction

18 Eur Heart Journal ,

19 Multivessel PCI during STEMI is associated with higher short- and long-term mortality HORIZONS-AMI 1 Meta-Analysis 2 1-time multivessel PCI Staged multivessel PCI Multivessel vs. Staged PCI Culprit vs. Staged PCI Culprit vs. Multivessel PCI 30 day mortality Odds Ratio 1. R Kornowski et al. JACC 2011;58: PJ Vlaar et al. JACC 2011;58:

20 What do the guidelines recommend? ESC - myocardial revascularization 2010 Emergency angiography and revascularization of all critically narrowed arteries by PCI/CABG as appropriate is indicated in patients in cardiogenic shock. Class of recommendation : Level of evidence: Evidence : SHOCK trial I B W Wijns et al. 2010

21 SHOCK trial: angiographic & PCI findings Multivessel disease 81% PCI of infarct related artery only 87% Complete revascularization 23% HD White et al. Circulation. 2005;112:

22 STEMI with MVD & cardiogenic shock: single or multivessel PCI? In hospital outcomes shock pts. National Cardiovascular Data Registry Odds ratios mortality 1 vessel PCI Multivessel PCI Patients p value 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 Multi- vs. 1-vessel PCI MA Cavender et al. Am J Cardiol 2009;104:

23 STEMI with MVD & cardiogenic shock: single or multivessel PCI? EHS-PCI registry T Bauer et al. Am J Cardiol 2012 in press.

24 Cardiogenic Shock: CABG or PCI for Left Main Disease? SHOCK trial & registry PCI procedural details Multivessel PCI 11.1% Stenting 28.4% IIB-IIIA used 6.6% Patients turned down by the surgeons? MS Lee et al. Ann Thorac Surg 2008;86:29-34

25 GRACE registry: unprotected left main revascularization in ACS Cumulative mortality In-hospital death PCI CABG PCI conservative CABG % P= ,4 40 P= P= Days since admission 0 all pts. n=1797 SCD or Shock n=59 STEMI or LBBB n=627 G Montalescot et al. Eur Heart J 2009; 30;

26 GRACE registry: unprotected left main revascularization in ACS Temporal trends in GRACE score severity (A) and type of revascularization (B) Timing of revascularization G Montalescot et al. Eur Heart J 2009; 30;

27 PCI for Left Main Disease in Acute MI Period Patients n Cardiogenic shock (%) Stents used (%) IIb-IIIa Used (%) Early Mortality (%) SHOCK Late Mortality (%) (follow up) G De Luca et al (37±23 months) SW Lee et al (39±22 months) MS Lee et al (586±431 days) CH Tan et al (420 days) SB Prasad et al (26±12 months) Pappalardo A et al (61% DES) GB Pedrazzini et al (78% DES) (CS) 10.5 (1 year) NA G De Luca et al. Am J Cardiol 2003;91: SW Lee et al. Int J Cardiol 2004;97:73-76 MS Lee et al. Ann Thorac Surg 2008;86:29-34 CH Tan et al. Int J Cardiol 2008;126: SB Prassad et al. Catheter Cardiovasc Interv 2009;73: A Pappalardo et al. JACC Intv. 2011;4; GB Pedrazzini et al. JACC Intv 2011;4;

28 Meta-analysis of IABP in STEMI : should we change the guidelines? Cardiogenic shock patients Beneficial effect of IABP with thrombolysis IABP pts younger IABP pts more rescue PCI No IABP in the sickest Detrimental effect of IABP with ppci IABP in transferred pts IABP in sickest pts KD Sjauw et al. Eur Heart J (2009) 30:

29 BCIS-1: Elective Intra-aortic Balloon Counterpulsation During High-Risk PCI Divaka Perera et al. JAMA. 2010;304(8):

30 IABP SHOCK II: No survival benefit of balloon pump in AMI with shock H Thiele, U Zeymer et al. N Engl J Med 2012;367:

31 Treatment Algorithm for Cardiogenic Shock Acute 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