Controversies in Cardiogenic Shock. Timothy D. Henry, MD Cedars-Sinai Heart Institute

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1 Controversies in Cardiogenic Shock Timothy D. Henry, MD Cedars-Sinai Heart Institute

2 Key Issues Cardiac Arrest-Cardiogenic shock interaction New SCAI Classification Refractory Shock Shock with Multivessel disease Shock centers and teams

3 Interaction of Cardiac Arrest and Cardiogenic Shock Cardiac Arrest (+) Cardiac Arrest ( ) Cardiogenic Shock (+) 184 Patients In-hospital Mortality: 47.3% 1 Year Mortality: 51.6% 259 Patients In-hospital Mortality: 25.1% 1 Year Mortality: 33.6% Cardiogenic Shock ( ) 317 Patients In-hospital Mortality: 20.2% 1 Year Mortality: 22.7% 4157 Patients In-hospital Mortality: 1.7% 1 Year Mortality: 5.5%

4 THOUGHTS ON SHOCK Not all shock is created equally What has held the field back is the lack of a common language Lingua Franca

5 INTERMACS: FOUNDED : Crash and Burn 2: Sliding on Inotropes 3: Dependent Stability 4: NYHA 4 5: Exertion Intolerant 6: Exertion Limited 7: Advanced NYHA III Stevenson et. Al. J Heart Lung Transplant

6 SCAI AND HFSA: EXPERT CONSENSUS ON CARDIOGENIC SHOCK CLASSIFICATION David Baran (HFSA) Srihari Naidu (SCAI) Steven Bailey (IC) Daniel Burkhoff (Cardiol Res) Cindy Grines (IC) Shelley Hall (AHF / Tx) Timothy Henry (IC) Steven Hollenberg (Critical Care) Navin Kapur (IC) William O Neill (IC) Joseph Ornato (Emergency Med) Frank Pagani (CT Surgery) Kelly Stelling (Shock Coord. Nursing) Holger Thiele (IC / Clin trials) Sean Van Diepen (Cardiol / Guidelines)

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8 STAGE A: AT RISK Physical Exam Bioxchem Markers Hemodyna mics Not Sick Normal Labs Normotensive A patient who is not currently experiencing signs or symptoms of CS but is at risk for its development. These patients may include those with NSTEMI, STEMI, acute or acute on chronic CHF Normal JVP Normal renal function Clear Lungs Normal lactic acid Warm/ Well Perfused Strong distal pulses Normal mentation SBP 100 or normal for pt If Swan in CI 2.5 CVP < 10 PA Sat 65

9 STAGE B: BEGINNING CS A patient who has clinical evidence of relative hypotension or tachycardia without hypoperfusion Physical Exam Not Sick Elevated JVP Bioxchem Markers Elevated BNP Minimal renal dysfunction Hemodyna mics SBP <90 OR MAP<60 or >30 mm drop from baseline Pulse 100 Normal Resp rate Rales in Lung fields Normal lactic acid If Swan in Warm/ Well Perfused CI 2.2 Strong distal pulses CVP < 10 Normal mentation PA Sat 65

10 STAGE C: CLASSIC CS A patient with hypoperfusion that requires interventions such as inotrope,pressor or perc. MCS other than ECMO to restore perfusion These patients typically have relative hypotension Physical Exam May Include any of: Sick, Looks unwell, panicked Ashen, mottled, dusky Bioxchem Markers: May Include any of Hemodyna mics: May Include any of Lactate 2 SBP<90 or MAP < 60 or > 30 mm drop from baseline AND drugs/ device used to maintain BP above these Creatinine doubling or > 50 % loss of GFR CI < 1.8 or < 2.2 on support Extensive rales Increased LFT s PCW < 15 BiPAP or Increased RA / CVP

11 STAGE D: DOOM / DETERIORATING Patients similar to C but are getting worse They have failure to respond to initial interventions Physical Exam May Include any of: Sick, Looks unwell, panicked Ashen, mottled, dusky Extensive rales BiPAP or mechanical vent Bioxchem Markers: May Include any of Lactate 2 Creatinine doubling or > 50 % loss of GFR Increased LFT s Increased BNP Hemodyna mics: May Include any of SBP<90 or MAP < 60 or > 30 mm drop from baseline CI < 1.8 or < 2.2 on support PCW < 15 Requiring multiple pressors or MCS to maintain perfusion

12 STAGE E: EXTREMIS Patient in cardiac arrest Physical Exam May Include any of: Trying to die Bioxchem Markers: May Include any of Lactate 5 Hemodyna mics: May Include any of No blood pressure without CPR with ongoing CPR or ECMO placement Being supported by Cardiac collapse Arterial ph 7.2 PEA or refractory VT/VF multiple interventions Mechanical Vent Increased LFT s Hypotension despite max support BiPAP or mechanical vent Increased BNP Defibrillated No time to draw

13 A IS FOR ARREST A the Arrest modifier Any CPR however brief

14 SIMPLE EASY TO REMEMBER: THE INTERMACS OF SHOCK

15 PATH FORWARD Finalize the classification and publish Examine different populations to see if stages of CS correlate with mortality Drive recognition of CS and earlier transfers to centers with full complement of tools Hopefully improve outcomes by identifying MCS and ECMO options that are appropriately matched to level of illnesss

16 RECENT EXAMPLES OF CARDIOGENIC SHOCK TRIALS IAB SHOCK 2 Trial Systolic BP < 90 for more than 30 min, or needed catecholamines to maintain systolic >90 Signs of pulmonary congestion Impaired end organ perfusion Altered mental status Cold clammy skin and extremities Oliguria (urine < 30/hr) Serum lactate > 2

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18 IMPELLA CP IN AMI SHOCK JACC, VOL. 6 9, NO. 3,

19 IMPRESS- IAB VS IMPELLA CP FOR SHOCK Multicenter, open label, randomized, N= 48 IAB vs Impella CP, 1:1 randomization STEMI with immediate PCI CS as defined by SBP < 90 for 30 minutes or requirement for inotropes / pressors to maintain SBP > 90 ALL Pts were VENTILATOR dependent to be enrolled! Informed consent WAIVED!

20 BASELINE Systolic BP mm Hg % had cardiac arrest Time to ROSC minutes mean Lactate mean ph % had LVEF < % had therapeutic hypothermia

21 IMPRESS- IAB VS IMPELLA CP FOR SHOCK Zeymer and Thiele. JACC Jan p

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23 Circulation 2017

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25 Early Transport to Cath Lab for ECMO and Revasc in Refractory VF (?OHCA)

26 Early Transport to Cath Lab for ECMO and Revascularization in Refractory Ventricular Fibrillation Out of Hospital VF/VT Initial rhythm DCCV x3 and 300mg Amiodarone without ROSC Time to CCL <30 min Initial CCL ABG and lactate Stop if: ETCO2<10mmHg, PaO2<50mmHg or Lactate >18 mmol/l If ROSC, immediate Cor Angio +/- IABP. If no ROSC, ECLS, then Cor Angio +/- IABP. Continue ACLS/ECLS for 90 minutes/pci; if no ROSC by 90 minutes, declared dead

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