Cardiogenic Shock in Acute MI
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1 Cardiogenic Shock in Acute MI Mark Sheldon, MD UNMH Interventional Cardiology
2 Objectives Overview Treatment Definition Shock profiles Causes Medical Mechanical Illustrative case Questions? Revascularization methods Basics of various methods of support
3 Pathophysiology Basics
4 CS Defined Low cardiac output/index < 1.8 l/min/m2 without support < l/min/m2 with support Relative hypotension < mmhg systolic Mean pressure < 60 mmhg Poor tissue oxygenation End organ failure
5 Hemodynamic Profiles Learntheheart.com
6 CS Epidemiology Incidence in MI decreasing since the 70 s: ~7% to <6% since the late 90 s Mortality rates decreasing: Why? Historically % Currently- about 50% (40-70%)
7 Causes LV pump failure (80%) RV pump failure (5-6%) Acute mitral valve insufficiency (7%) Ventricular rupture (<2%) or VSD (4%) Concomitant aortic/mitral stenosis Others
8 Clinical manifestations Hypotension Hypoperfusion: Oliguria Cool extremities Altered mental status Pulmonary congestion Metabolic acidosis Elevated Lactate
9 Treatment-Medical Usual medical therapy Aspirin Clopidogrel/Ticagrelor/Prasugrel Heparin Avoid beta blockers Inotropes/Pressors Hypotensive: Dopamine/Norepinephrine Not hypotensive: Dobutamine
10 Treatment-Mechanical Revascularization SHOCK trial PPCI greatly preferred over fibrinolytics Culprit artery first Multi-vessel revascularization? PCI vs. Surgery
11 SHOCK Trial
12 Treatment-Mechanical Intra-aortic balloon pump Left ventricular assist devices Impella(percutaneous) Tandem Heart (percutaneous) LVAD (surgical) ECMO (surgical/percutaneous)
13 IABP Mechanics nmcheartcare.ae
14 IABP Arterial Waveform Ganfyd.org
15 ImpellaCatheter Abiomed.com
16 Impellapositioning medpagetoday.com
17 ECMO Circuit ecmosimulation.com
18 Treatment of Cardiogenic Shock: Recommendations-ACC/AHA CLASS I Emergency revascularization with either PCI or CABG is recommended in suitable patients with cardiogenic shock due to pump failure after STEMI irrespective of the time delay from MI onset (212,379,452). (Level of Evidence: B) In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI and cardiogenic shock who are unsuitable candidates for either PCI or CABG (81,453,454). (Level of Evidence: B)
19 Treatment of Cardiogenic Shock: Recommendations-ACC/AHA CLASS IIa The use of intra-aortic balloon pump (IABP) counterpulsationcan be useful for patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological therapy (455,456,457,458,459). (Level of Evidence: B) CLASS IIb Alternative LV assist devices for circulatory support may be considered in patients with refractory cardiogenic shock. (Level of Evidence: C)
20 Guideline Evolution More recent European Guidelines deemphasized IABP s and brought up the recommendations for percutaneous LVAD s (Impella)
21 Case
22 CS 1 68 yowoman with a history of HTN, HLP, active smoking, known CAD, s/p BMS of the RCA for an ACS 8 years ago. Also has a history of poor medical compliance and has not seen a physician for 5+ years. Chest discomfort then N/V >> collapsed at home VF found and shocked x 4, CPR, + 3 mg epi and 70 mg lidocaine with ROSC Intubated and brought to UNMH ED
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24 UNMH ED Vitals: 70/40, 75, intubated Pulse was lost (PEA) and CPR resumed with more Epi given and amiodarone/shock given for pulseless VT ROSC with a blood pressure of 185/100, then down to the 90 s systolic >> dopamine begun Taken to the cathlab
25 UNM Cath Lab Upon arrival to the cathlab bradycardic and hypotensive again TVP placed Norepinephrine begun
26 Angios
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32 After RCA stents x 2-still hypotensive requiring IABP and dopamine/norepinephrine What next? Impella? ECMO? Further Revasc?
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34 Hospital Course Dopamine weaned off in the cathlab prior to transfer <24 hours- norepinephrine weaned off 36 hours- IABP removed and extubated Full neurologic recovery LVEF on TTE 45-50% with inferior hypokinesis Discharged on Hospital day 6
35 Any Further Questions Mark Sheldon Phone:
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