Acute Myocardial Infarction Complicated by Cardiogenic Shock

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1 Acute Myocardial Infarction Complicated by Cardiogenic Shock Navin K. Kapur, MD, FACC, FSCAI Assistant Professor, Division of Cardiology Director, Acute Circulatory Support Program Director, Interventional Research Laboratories Investigator, Molecular Cardiology Research Institute

2 Is this STEMI patient in Cardiogenic Shock? 56 year old man with new onset stuttering chest pain 24 hours prior to ED presentation. Persistent 3/10 chest pain. Initial ECG shows inferior ST-segment elevation (1-2mm). HR: 100 BP: 110/80 RR: 24 O2 Sat:98% FM JVP: N/A. + S1/S2, +S4. No murmur. No rub. Cool lower extremities. No edema. + Cutis marmorata. Echocardiogram while prepping: LVEF 35% Inferopost akinesis No VSD. No MR. RV normal. No pericardial effusion. Yes, No, Maybe, or it doesn t matter?

3 Defining Cardiogenic Shock SHOCK Trial ( ): Early revascularization vs Medical Therapy Clinical criteria SBP<90 mm Hg for >30 minutes or supportive measures to maintain SBP>90 and Hypoperfusion (cool extremities, urine output of <30 ml per hour, and HR>60) Hemodynamic criteria Cardiac index < 2.2 LPM/BSA NB: Contemporary definition: CI <2.2 on pharmacologic support or <1.8 without therapy PCWP >15 mm Hg. Pulmonary artery catheterization was not required if anterior MI with CHF. Early Shock: < 36 hours after myocardial infarction; randomization <12 hours after the diagnosis of shock Exclusion Criteria: Severe systemic illness, mechanical or other cause of shock, severe valvular disease, dilated cardiomyopathy, the inability of care givers to gain access for catheterization, and unsuitability for revascularization.

4 LVEF Does Not Define Cardiogenic Shock Broad Range of LVEF in the SHOCK Trial Mean LVEF = 30% Reynolds and Hochman. Circulation. 2008;117:

5 This differential should be running through your mind Tamponade/rupture Isolated RV Shock 1.7% Other 7.5% 3.4% VSD 4.6% Acute Severe MR 8.3% Predominant LV Failure : 74.5% Shock Registry JACC :1063

6 Despite increasing use of PCI and IABP, mortality remains high in cardiogenic shock. Jeger RV et al Ann Intern Med Nov 4;149(9):618-26

7 What would you do? STEMI and Shock Next steps? 1. LCx PCI 2. RHC 3. IABP 4. Impella CP 5. TandemHeart 6. CABG

8 Rapid Reperfusion Limits Myocardial Damage (Door to Balloon) Door to Balloon Angioplasty (DTB) US National Heart Attack Alert Program (NHAAP)

9 Long-term Benefits of Early Treatment

10 Something to keep in mind: No incremental impact of DTB << 90 min on mortality in Anterior MI or Cardiogenic Shock N Engl J Med 2013;369:901-9

11 What would you do? STEMI and Shock Next steps? 1. LCx PCI 2. RHC 3. IABP 4. Impella CP 5. TandemHeart 6. CABG

12 What would you do? STEMI and Shock Initiated bivalirudin Administered Prasugrel Prepared for PCI Started with a RHC Rationale: 1. We are going to open this vessel. 2. If he is in shock, I d like to know since reperfusion may worsen his already marginal hemodynamic status. 3. An RA sat of 30% vs 90% might alter my approach here (both being bad). Initial RHC RA 12 PA 36/18 PCWP 24 Fick CI 1.5 PA Sat 43% FA Sat 99% MAP 70 SVR 2400 Na+ (meq/l) 136 Creatinine 1.1

13 Pathophysiology of Acute MI / Cardiogenic Shock TNF-a IL-6 SVR often normal In contrast, to chronic HF Circulation 1999

14 The Hemodynamics of AMI vs AMI + Shock Pressure Stroke Volume Ees LVEDP or LVEDV Volume Condition 1: Normal Condition 2: Acute Myocardial Infarction Condition 3: Cardiogenic Shock Kapur et al. HF Clinics 2014

15 In-Hospital Mortality (%) Predicting Survival in AMI / Shock Fincke et al JACC 2004 CPO = Cardiac Power Output (CPO) MAP x CO 451

16 Biomarkers of Survival in AMI/Shock Lauten et al. JACC: Heart Failure 2013

17 What would you do? STEMI and Shock Initial RHC RA 12 PA 36/18 PCWP 24 Fick CI 1.5 PA Sat 43% FA Sat 99% MAP 70 SVR 2400 Na+ (meq/l) 136 Creatinine 1.1 This RHC data alters my approach: First stabilize his hemodynamics, then revascularize when safe to do so Caveat: Many would recommend opening the culprit artery first.

18 Is there Support for Mechanical Support in AMI/Shock? IABP-SHOCK II Randomized ACS patients with clinically defined shock to PCI withversus without- IABP support. STEMI and Non-STEMI 45% Anterior infarct CGS: hypotension / poor perfusion IABP use pre- or post-pci Median LVEF : 35% No PA catheter indices Thiele H et al. NEJM 2012

19 Is there Support for Mechanical Support in AMI/Shock? IABP-SHOCK II Randomized ACS patients with clinically defined shock to PCI withversus without- IABP support. Interpretation: Uniform use of IABP in ACS and Shock is unnecessary. Questions: 1. Unloading stable patients with ACS? 2. Timing of IABP pre- vs post-pci? 3. No assessment of IABP function? Conclusion: Hard to make statements about unloading without hemodynamic data. Thiele H et al. NEJM 2012

20 Medscape: A Hard Look at Cardiogenic Shock. 2012

21 USPella: STEMI and Shock Subset Analysis Pre- vs Post-PCI Impella Activation

22 USPella: STEMI and Shock Subset Analysis Pre- vs Post-PCI Impella Activation

23 What would you do? STEMI and Shock Initial RHC RA 12 PA 36/18 PCWP 24 Fick CI 1.5 PA Sat 43% FA Sat 99% MAP 70 SVR 2400 Na+ (meq/l) 136 Creatinine 1.1

24 First Unload Initial RHC Impella CP 3.4 LPM RA 12 RA 120 PA 36/18 PA 32/16 PCWP 24 PCWP 20 Fick CI 1.5 Fick CI 2.4 PA Sat 43% PA Sat 54% FA Sat 99% FA Sat 99% MAP 70 MAP 72 SVR 2400 SVR 2000 Na+ (meq/l) 136 Na+ (meq/l) 136 Creatinine 1.1 Creatinine 1.1

25 Then Reperfuse O2 Demand O2 Supply First Unload. 25 then Reperfuse Myocardial Perfusion

26 Final Food for Thought: How did we get to where we are today? 76% 39% 10% Ezekowitz JA et al JACC 2009

27 Take Home Messages Cardiogenic shock can be defined clinically at the bedside or using specific hemodynamic criteria. Mentally run through the cardiogenic shock differential check list before you revascularize in STEMI + Shock Early reperfusion saves lives. Do NOT ignore the importance of the door to balloon time. More rapid reperfusion (< 90 mins DTB) may not benefit all patients with cardiogenic shock. Hemodynamic interrogation helps you stratify patients and define your therapeutic strategy.

28 Thank you.

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