Cardiogenic shock: Current management Janine Pöss Universitätsklinikum des Saarlandes Klinik für Innere Medizin III Kardiologie, Angiologie und internistische Intensivmedizin Homburg/Saar
I have nothing to disclose.
Definition and characteristics Cardiogenic shock Clinical state of hypoperfusion caused by critical reduction in cardiac performance Life-threatening manifestation of acute heart failure
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 0 5 10 15 20 25 30 35 40 Mortality (%) Nieminen et al., Eur Heart J 2006
Guidelines
German-Austrian S3 guideline Diagnosis, monitoring and therapy of cardiogenic shock due to myocardial infarction Werdan et al., Dtsch Arztebl Int. 2011
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
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
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
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
Drug therapy Revascularization Mechanical assist Treatment Goals Restoration of perfusion and oxygenation of myocardium and other vital organs Prevention of MODS Stabilization, monitoring
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
Revascularization Shock = emergency indication for revascularization
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
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
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
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
Proportion Überleben surviving (rel. (rel. %) %) Levosimendan vs Dobutamine SURVIVE 100 90 80 70 60 50 1327 patients with ADHF, need for inotropic support Levosimendan Dobutamine 180-day mortality: 27% p=n.s. 40 0 30 60 90 120 150 180 Time (days) Levosimendan (or a PDE inhibitor) may be considered if effects of dobutamine are insufficient IIb C Mebazaa et al.jama 2007
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
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
Vasopressors SOAP- II trial 1679 patients with shock OR 0.75, p = 0.03 Norepinephrine = Vasopressor of choice De Backer et al., NEJM 2010
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!
Drug therapy Revascularization Mechanical assist Goals Restoration of perfusion and oxygenation of myocardium and other vital organs Prevention of MODS Adanced hemodynamic monitoring
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
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 0.0022 Most important independent predictor of mortality in patients with cardiogenic shock (Fincke et al., JACC 2004)
Advanced hemodynamic monitoring German-Austrian S3 guideline Cardiogenic shock Measuring blood pressure is not enough! Add flow-monitoring (Cardiac output)! Target corridors: MAP 65-75 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
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
mm Hg IABP 140 Diastolic augmentation 120 100 Non assisted systole Ballooninflation Assisted systole 80 60 Non assisted enddiastolic pressure Assisted enddiastolic pressure Coronary perfusion Afterload Oxygen consumption
IABP: ESC guidelines IABP recommended in STEMI complicated by cardiogenic shock IC
Metaanalysis: IABP vs no IABP n = 10.529 patients with ICS 30 day mortality No reperfusion: - 29 % Thrombolysis: - 18 % Primary PCI: + 6 % Urgent need for randomized trial! Sjauw et al., EHJ 2009
IABP Urgent need for randomized controlled trials
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
Drug therapy Revascularization Mechanical assist Goals Restoration of perfusion and oxygenation of myocardium and other vital organs Prevention of MODS Stabilization, monitoring
MODS Cardiogenic shock Cardiogenic shock & SIRS
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
Expansion of traditional treatment goals Achieve early revascularization Improve coronary and cerebral perfusion Prevent and treat SIRS and MODS and optimize intensive care
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
Thank you for your attention! Dr. med. Janine Pöss Klinik für Innere Medizin III Universitätsklinikum des Saarlandes Homburg/Saar, Germany Tel. 06841-16-23000 Janine.poess@uks.eu