Cardiogenic shock: Current management

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1 Cardiogenic shock: Current management Janine Pöss Universitätsklinikum des Saarlandes Klinik für Innere Medizin III Kardiologie, Angiologie und internistische Intensivmedizin Homburg/Saar

2 I have nothing to disclose.

3 Definition and characteristics Cardiogenic shock Clinical state of hypoperfusion caused by critical reduction in cardiac performance Life-threatening manifestation of acute heart failure

4 EuroHeart Failure Survey II: Mortality of acute heart failure profiles N=3580 Right HF Hypertensive HF Pulmonary edema Decompensated HF De novo AHF ADHF Cardiogenic shock Mortality (%) Nieminen et al., Eur Heart J 2006

5 Guidelines

6 German-Austrian S3 guideline Diagnosis, monitoring and therapy of cardiogenic shock due to myocardial infarction Werdan et al., Dtsch Arztebl Int. 2011

7 Drug therapy Revascularization Mechanical assist Management of cardiogenic shock Goals Restoration of perfusion of myocardium and other vital organs Prevention of MODS Diagnosis, stabilization, monitoring

8 Drug therapy Revascularization Mechanical assist Management of cardiogenic shock Goals Restoration of perfusion and oxygenation of myocardium and other vital organs Prevention of MODS Diagnosis, stabilization, monitoring

9 Diagnosis Clinical signs: Cold, pale, diaphoretic skin Oligo-/anuria ( 30 ml/h) Alteration in mental status Hemodynamic signs: Hypotension Catecholamines or IABP Advanced hemodynamic monitoring: NOT REQUIRED FOR DIAGNOSIS

10 Monitoring and initial assessment Monitoring: ECG, invasive blood pressure Respiratory rate, oxygen saturation Urine output Further assessment: Physical examination Laboratory parameters, arterial blood gas analysis Chest X-ray Echocardiography

11 Drug therapy Revascularization Mechanical assist Treatment Goals Restoration of perfusion and oxygenation of myocardium and other vital organs Prevention of MODS Stabilization, monitoring

12 SHOCK trial: Benefit of revascularization Randomized, n=302 patients with infarction-related cardiogenic shock 13% ARR for mortality NNT <8 Optimal treatment of CS demands early reperfusion! Hochman et al., JAMA 2006

13 Revascularization Shock = emergency indication for revascularization

14 Drug therapy Revascularization Mechanical assist Treatment Goals Restoration of perfusion and oxygenation of myocardium and other vital organs Prevention of MODS Stabilization, monitoring on intensive care unit

15 Inotropes Dobutamine Ca 2+ ß- receptor G s Adenylatcyclase G i P ATP camp PDE-III- Inhibitors Phosphodiesterase Proteinkinase A Ca 2+ 5-AMP Levosimendan

16 Inotropes - Dobutamine Inotrope of choice Should be considered in patients with hypotension and/or hypoperfusion IIa C Dobutamine ß- receptor G s Adenylatcyclase G i ATP camp

17 Survival (%) Inotropes may increase mortality FIRST trial e No Dobutamine Dobutamine e Follow-up (years) O Connor et al., Am Heart J 1999 Should be reserved for patients with such severe reduction in CO that vital organ perfusion is compromised IIa C

18 Proportion Überleben surviving (rel. (rel. %) %) Levosimendan vs Dobutamine SURVIVE patients with ADHF, need for inotropic support Levosimendan Dobutamine 180-day mortality: 27% p=n.s Time (days) Levosimendan (or a PDE inhibitor) may be considered if effects of dobutamine are insufficient IIb C Mebazaa et al.jama 2007

19 Proportion Überleben surviving (rel. (rel. %) %) Levosimendan vs Enoximone 32 patients with refractory CS Levosimendan (n=16) Enoximone (n=16) Time (days) Fuhrmann. et al., Crit Care Med 2008

20 Vasopressors Norepinephrine Predominant a1-stimulation potent vasoconstriction Dopamine < 3 µg/kg/min: D 1/2 receptor vasodilation 3-10 µg/kg/min: b1 receptor inotropy > 10 µg/kg/min: a1 receptor vasoconstriction May be considered if shock persists despite treatment with an inotrope IIb C

21 Vasopressors SOAP- II trial 1679 patients with shock OR 0.75, p = 0.03 Norepinephrine = Vasopressor of choice De Backer et al., NEJM 2010

22 Inotropes/vasopressors - Summary Dobutamine inotrope of choice Norepinephrine vasopressor of choice Levosimendan (or PDE-I) refractory shock Use catecholamines as long as necessary at the lowest possible dose!

23 Drug therapy Revascularization Mechanical assist Goals Restoration of perfusion and oxygenation of myocardium and other vital organs Prevention of MODS Adanced hemodynamic monitoring

24 Advanced hemodynamic monitoring No randomized controlled data in patients with cardiogenic shock! Should be considered IIb C No general role. Should be considered in patients refractory to treatment

25 Advanced hemodynamic monitoring Advantages: Confirm diagnosis Guide therapy in persistent shock or contradictory clinical signs Provide hemodynamic data with powerful predictive value Cardiac Power Output (W) = CO x MAP x Most important independent predictor of mortality in patients with cardiogenic shock (Fincke et al., JACC 2004)

26 Advanced hemodynamic monitoring German-Austrian S3 guideline Cardiogenic shock Measuring blood pressure is not enough! Add flow-monitoring (Cardiac output)! Target corridors: MAP mm Hg AND Cardiac Index > 2,5 l/min x m -2 and/or Cardiac Power Index > 0,4 W x m -2 Werdan et al., Dtsch Arztebl Int. 2011

27 Drug therapy Revascularization Mechanical assist Goals Restoration of perfusion and oxygenation of myocardium and other vital organs Prevention of MODS Stabilization, monitoring on intensive care unit

28 mm Hg IABP 140 Diastolic augmentation Non assisted systole Ballooninflation Assisted systole Non assisted enddiastolic pressure Assisted enddiastolic pressure Coronary perfusion Afterload Oxygen consumption

29 IABP: ESC guidelines IABP recommended in STEMI complicated by cardiogenic shock IC

30 Metaanalysis: IABP vs no IABP n = patients with ICS 30 day mortality No reperfusion: - 29 % Thrombolysis: - 18 % Primary PCI: + 6 % Urgent need for randomized trial! Sjauw et al., EHJ 2009

31 IABP Urgent need for randomized controlled trials

32 IABP-Shock-II Trial Primary endpoint: 30 day mortality Acute MI (STEMI / NSTEMI) Shock Inclusion criteria PCI (CABG) Randomization Hypoperfusion Hemodynamik SBP < 90 mmhg or vasopressors IABP-SHOCK II- Registry Conventional treatment Vasopressors Inotropics Mechanical ventilation + IABP (n=300) Conventional treatment Vasopressors Inotropics Mechanical ventilation - IABP (n=300) Thiele et al., EHJ 2012

33 Drug therapy Revascularization Mechanical assist Goals Restoration of perfusion and oxygenation of myocardium and other vital organs Prevention of MODS Stabilization, monitoring

34 MODS Cardiogenic shock Cardiogenic shock & SIRS

35 Prognostic indicators in cardiogenic shock IABP SHOCK Trial, n = 40 ROC Curve Parameter AUC APACHE II 0,850 Cardiac index 0,771 Interleukin 6 0,769 BNP 0,502 Prondzinsky et al., Crit Care Med 2010

36 Expansion of traditional treatment goals Achieve early revascularization Improve coronary and cerebral perfusion Prevent and treat SIRS and MODS and optimize intensive care

37 Summary: Cardiogenic shock Life-threatening manifestation of acute heart failure Optimal treatment of CS demands early reperfusion Catecholamines: Lowest possible dose! As long as necessary! Persistent shock - advanced hemodynamic monitoring required! IABP: Urgent need for randomized data Results IABP-Shock-II Optimization of intensive care for prevention of MODS

38 Thank you for your attention! Dr. med. Janine Pöss Klinik für Innere Medizin III Universitätsklinikum des Saarlandes Homburg/Saar, Germany Tel

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