How to do Primary Angioplasty - Patients with Cardiogenic Shock Advanced Cardiovascular Intervention 2011 Dan Blackman Leeds General Infirmary
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Causes of Cardiogenic Shock Tamponade/rupture 1.7% Isolated RV Shock 3.4% Other 7.5% VSD 4.6% Acute Severe MR 8.3% Shock Registry JACC 2000 35:1063 Predominant LV Failure 74.5%
In-hospital Mortality (%) Survival from mechanical causes 100% 90% 94% No Surgery Surgery Percutaneous closure 80% 70% 71% 60% 50% 47% 40% 39% 30% 28% 20% 10% 0% VSD Shock Registry JACC 2000;36:1104 & 36: 1110 Acute Severe MR GUSTO 1 Circulation 2000;101:27 Holzer R CCI 2004;61:196
Mortality (%) Emergency revascularisation - SHOCK Trial 90% 80% 70% p=0.11 p=0.03 63% p=0.03 66% p=0.02 67% 80% ERV IMS 60% 50% 47% 56% 50% 53% 40% 30% 20% 10% 0% 30 days (n=302) 6 months (n=301) 12 months (n=299) 6 years 85% of survivors NYHA Class I/II at 12 months Hochman JAMA 2000;285:190
1-year mortality (%) Single or Multi-vessel PCI? 81% of PCI patients multi-vessel disease 85% PCI IRA only; 23% complete revascularisation 90% 80% 80% 70% 60% 50% p<0.01 45% p=ns 50% p=ns 54% 46% 40% 39% 30% 20% 10% 0% MV PCI SV PCI Complete Partial Shock Trial MV PCI SV PCI Shock Registry
1-year mortality (%) Role of CABG 60% 53% p=ns 50% 48% 46% 40% 30% 20% 24% PCI CABG 10% 0% SHOCK Trial SHOCK Registry n=81 n=47 n=276 n=109 SHOCK Trial CABG vs PCI baseline characteristics LMS Disease 41% vs 13% p=0.051 3VD 80% vs 60% p=0.18 Diabetes 49% vs 27% p=0.11
AHA/ACC Guidelines for Revascularisation
PCI Strategy in Cardiogenic Shock Stabilise the patient first, open the vessel second Up-front IABP Central venous access Inotropic/Pressor support as required Anaesthetic support in the cath lab
SOAP II Comparison of Dopamine and Norepinephrine in Shock 1679 patient RCT in shock 280 patients cardiogenic Increased arrythmia with dopamine (AF/VT/VF) Significantly lower mortality with norepinephrine in CS Vasoconstriction (by SVR) is often absent* Patients with vasoconstriction have better outcome* De Backer, NEJM, 2010;362:779.
Cardiogenic Shock Systolic BP >100mmHg Systolic BP 70-100mmHg NO Shock Systolic BP 70-100mmHg With Shock Systolic BP <70mmHg With Shock Nitroglycerin 10-20mcg/min Dobutamine 2-20mcg/kg/min Dopamine 5-15mcg/kg/min Norepinephrine 1-30mcg/kg/min Antmen, JACC, 2004;44:671
30 day Mortality (%) Abciximab in Cardiogenic Shock 70% 60% 62% PCI PCI +Abciximab 50% 44% 44% 40% 36% 39% 30% 20% 22% 26% 22% 21% 10% 9% 0% Antoniucci (stent) n=77 Chan Stent Chan PTCA Giri (50% stent) n=41 n=55 n=113 ADMIRAL (stent) n=25
Event rate (%) 80 patient RCT PRAGUE-7 study Up-front (n=40) vs provisional (n=40) abciximab in PPCI for cardiogenic shock 120% 100% 100% Up-front Provisonal 80% P=NS for all 60% 40% 35% 37% 32% 42% 27% 20% 10% 5% 0% Abciximab given Mortality MACE TIMI Major Bleeding
Mortality (%) Intra-aortic balloon pump counterpulsation 80 70 60 63 69 59 68 TT only TT + IABP 50 47 49 43 45 40 34 30 20 23 10 0 Shock Registry (n=292) NRMI Registry (n=23,180) TACTICS GUSTO I & III Kovack (n=46)
In-hospital Mortality (%) IABP in Cardiogenic Shock Primary PCI Retrospective analysis of 23,180 patients from NRMI database 7268 treated by IABP 80 70 67 60 50 40 49 42 46 30 20 10 0 Thrombolysis only Thrombolysis + IABP Primary PCI only Primary PCI + IABP
Event rate (%) Timing of IABP in Cardiogenic Shock Primary PCI 40% 35% 35% IABP pre (n=62) IABP post/none (n=57) 35% 30% 30% 25% 20% 15% 15% 13% 15% 10% 5% 0% CPR VF/VT arrest Any event Single centre registry Primary PCI for shock Brodie AJC 1999;84:18
Left atrial-to-femoral arterial LVAD Low speed centrifugal continuous flow pump 21F venous transeptal cannula 17F arterial cannula Maximum flow 4L/minute Expensive +++ Tandem Heart plvad
30 day mortality (%) Tandem Heart Outcome Data 50% 45% 42% 45% p=ns 47% Tandem Heart IABP 40% 35% 36% 30% 25% 20% 15% 10% 5% 0% Thiele (n=41) Burkhoff (n=33) Improved haemodynamic parameters Increase in bleeding, limb ischaemia, and sepsis Thiele EHJ 2005;26:1276. Burkhoff AHJ 2006;152:e1
Impella Axial flow pump Much simpler to use Increases cardiac output & unloads LV LP 2.5 12 F percutaneous approach; Maximum 2.5 L flow LP 5.0 21 F surgical cutdown; Maximum 5L flow Expensive ++ Blood Inlet Motor Blood outlet Pressure Lumen
Impella outcome data ISAR-SHOCK 26 patient RCT Impella vs IABP Cardiac Index, MAP (by 10mmHg) vs IABP Complications IABP No difference in mortality PROTECT-II 654 patients RCT IABP vs Impella in high-risk PCI Stopped after n= 305 due to futility Primary EP composite of 10 MAEs Incidence 38% Impella vs 43% IABP
How to treat STEMI + Cardiogenic Shock Emergency angiography and revascularisation On-table echo to rule out mechanical defects Stabilise the patient in the lab before revascularisation IABP Central venous access Pressors if required Norepinephrine (dopamine) Anaesthetic support Consider calling the surgeon for true surgical disease PCI culprit artery. Consider other vessels if shock persists. Staged PCI or CABG if patient stabilises Consider percutaneous VAD if shock persists with IABP + effective revascularisation
ESC Guidelines for Cardiogenic Shock
Revascularisation: SHOCK trial STEMI complicated by shock due to LV failure n= 302 Hypotension (SBP<90mmHg), End organ hypoperfusion, CI<2.2, PCWP>15mmHg Randomised within 36 hours of index event Emergency Revascularisation (152) PCI or CABG within 6hr IABP recommended Medical (150) IABP Revasc at 54 hours PCI = 81 and CABG = 47 Primary endpoint: 30 day mortality Secondary endpoint: 6 and 12 month mortality Late follow-up
NYHA I-II NYHA III-IV Death Sleeper, JACC, 2005; 46:266. Heart Attack: The Challlenge, Manchester 2010 Shock: Incidence, Diagnosis, Treatment, Outcome
30-day Mortality (%) Emergency revascularisation in the Elderly - SHOCK Trial 80% 70% 75% p=0.01 ERV IMS 60% p=0.01 57% 53% 50% 40% 41% 30% 20% 10% 0% <75 years (n=246) >75 years (n=56) >75 years ERV vs IMS baseline characteristics LVEF 28% vs 36% p=0.051 Anterior MI 63% vs 41% p=0.18 Female 54% vs 31% p=0.11
30-day Mortality (%) Elderly - SHOCK & other registry data 90% 80% 70% 81% ERV IMS 60% 50% 48% 47% 46% 40% 30% 20% 10% 0% SHOCK Registry Mayo Clinic Northern New n=44 n=233 n=61 England n=74
Why worry about Cardiogenic Shock? Cardiogenic shock complicates 6-8% of STEMI * Mortality is 60.1% ** It is the leading cause of death from STEMI * GUSTO, NRMI, GRACE ** Shock registry JACC 2000
ESC Guidelines for Revascularisation Complete revascularisation has been recommended with PCI in all critically stenosed large epicardial coronary arteries
Right Ventricular Infarction (3%) Shock with clear lungs Elevated JVP ECG and echo Maintain preload Reduce RV afterload Maintain AV synchrony
Mortality by PCI outcomes 100 90 80 70 60 50 40 30 20 10 0 55 100 38 39 1 2 3 2 1-0 TIMI FLOW 85 SuccUnsucc PCI Webb, JACC 2003;42:1380.
Percutaneous left ventricular assist devices Even with revascularisation and IABP support mortality from cardiogenic shock post STEMI remains 50% Recovery of myocardial performance following successful revascularisation may take several days. During this time many patients succumb to low cardiac output Efficacy of IABP is limited by the lack of active cardiac support, requirement for a certain level of LV function, and the need for accurate synchronisation with cardiac cycle Patients with severely impaired LV function and/or persistent tachyarrhythmias derive little benefit from IABP
Management Principles Diagnose & treat causes other than LV failure Support cardiac output and organ perfusion Inotropes / pressors Mechanical support Early Revascularisation PCI/CABG
Agent Inotropes and Vasopressors Dose μg/min α vasoconstrict β Inotropy/vasodilate Arrhythmia Epinephrine 2-10 ++ +++ +++ Norepinephrine 0.5-30 +++ ++ ++ Dopamine 5-10 ++ ++ ++ 10-20 +++ +++ +++ Dobutamine 2-20 + +++ ++ Isoproterenol 2-10 0 +++ +++ Vasoconstriction (by SVR) is often absent* Patients with vasoconstriction have better outcome* * SHOCK Data
PCI + staged CABG Chiu et al Single centre retrospective registry study PCI only vs PCI + staged CABG for cardiogenic shock with multivessel disease Propensity matched n=44 in each group 1.3 vessels revascularised by PCI; 2.6 by CABG 30-day mortality 20.5% PCI + CABG vs 40.9% PCI only