CardiogenicShockNTCardiovascularCenter：心源性休克NT心血管中心课件

1、Cardiogenic ShockNick Tehrani, MDCardiogenic ShockNick Tehrani,Definition90 mmHg15 mmHgDefinition90 mmHg 65Female genderLarge infarctionAnterior infarctionPrior infarctionDMPrior HTNRisk Factors for Cardiogenic SPost-mortem study of Shock heartsAt least 40% of the myocardium infarcted in the aggrega

2、te (old and new injury)80% have significant LAD disease2/3 have severe 3VdzPost-mortem study of Shock heaOutcomes of Cardiogenic ShockHistoric mortality 60-80%More recently reported mortality numbers67% in the SHOCK trial registry56% in GUSTO-I(v.s. 3% in Pts. without shock)Outcomes of Cardiogenic S

3、hockHOutcomes of Cardiogenic ShockThe ST pattern in Cardiogenic shock: 15-30 % Non-ST elevation MIOlderMortality: 77% 70-85% ST elevations MI/ New LBBBMortality: 53-63%SHOCK registry findings on this pointOutcomes of Cardiogenic ShockTOutcomes of Cardiogenic ShockThe SHOCK registrySimilar mortality

4、in the two groups62.5% in non-ST elevation60.4% with ST elevationOutcomes of Cardiogenic ShockTPathophysiology of ShockEffect of HypotensionFlow in normal coronary:Regulated by microvascular resistanceCoronary flow may be preserved at AO pressures as low as 50 mm HgIn coronary vessel with critical s

5、tenosis:Vasodilator reserve of microvascular bed is exhaustedDecrease in AO pressure = Coronary hypoperfusionPathophysiology of ShockEffectPathophysiology of ShockEffect of Hypotension (continued)Normal heart extracts 65% of the O2 present in the blood Little room for augmentation of O2 extractionPa

6、thophysiology of ShockEffectPathophysiology of Shock Effect of: Elevated LVEDP on coronary flowLVEDP(mm Hg)Pathophysiology of Shock EffecPathophysiology of ShockHypotension + LVEDP and critical stenosis Myocardial Hypoperfusion LV dysfunction Systemic lactic acidosis Impairment of non-ischemic myoca

7、rdium worsening hypotension.Pathophysiology of ShockHypotSchematicLVEDP elevationHypotensionDecreased coronary perfusionIschemiaFurther myocardial dysfunctionNeurohormonal activation VasoconstrictionEndorgan hypoperfusionSchematicLVEDP elevationMedical Stabilization of Shock Pts.Figure out the volum

8、e status, Swan if in doubtAir wayJudicious afterload reductionMaintain AV synchronyDont tolerate AfibDual chamber pacing if A-V block presentCorrect Acid-Base disturbancesMaintain BP ( IABP and/or Pressors).Medical Stabilization of ShockPhysiologic Effect of IABP in-vivoDecreased afterload LV O2 con

9、sumption Williams, et.al., Circulation 1982Kern, et.al., Circulation 1993Coronary blood flow velocity was measured using doppler-wire in nine patients with critical stenotic lesions. Peak diastolic coronary flow velocity beyond the stenosis was unaffected by intra-aortic balloon pumping.There was un

10、equivocal IABP-mediated augmentation of both proximal and distal coronary blood flow velocities post PTCA.Physiologic Effect of IABP in-Physiologic Effect of IABP in-vivoFuchs, et.al., Circulation, 1983Great cardiac vein flow was measured in seven patients receiving maximal drug therapy and requirin

11、g balloon pumping for unstable angina.All patients had greater than 90% stenosis of the proximal LAD coronary artery.Increased great cardiac vein flow correlated with increased mean aortic diastolic pressure across changes in balloon volumes (off, 20 cc, 30 cc, and 40 cc) and changes in assist ratio

12、 (off, 1:4, 1:2, and 1:1) (p = .02).Physiologic Effect of IABP in-Physiologic Effect of IABP in-vivoThus balloon pumping increased flow to a bed fed by the critical stenosis, or collateral vesselsPhysiologic Effect of IABP in-IABP in Acute MIJACC 1985IABP in Acute MIJACC 1985IABP in Acute MIPre-thro

13、mbolytic eraNo Lytics, ASA, or Lopressor20 patients with Acute MI and “extensive myocardium at risk per baseline Thalium” were Randomized.Pt.s in Shock were excludedStd. Rx:O2, MSo4, Lido, HeparinStd Rx+IABP Plus IV NTGIABP in Acute MIPre-thrombolytIABP in Acute MIPatients had repeat Thalium scan on

14、 Day-4No differences were observed between the two groups regarding:-Thalium defect score comparing days 1 and 4-The ejection fraction comparing days 1 and 4=“Unlikely that a mortality benefit is conferred by the IABP/NTG combination”IABP in Acute MIPatients had rUtility of IABP in Shock Pts.Observe

15、d clinical benefits:Improved acid-base statusImproved urine outputImproved mentationImproved overall hemodynamicsAll this, however, does not add up to improved survival without Flow RestorationUtility of IABP in Shock Pts.OThrombolysis in Cardiogenic ShockRates of Reperfusion Lower, andRates of Reoc

16、clusion HigherThan in non-shock ptsPossible Reason:Diffusion of thrombolytic agent into the thrombus may be PRESSURE DEPENDENT.Thrombolysis in Cardiogenic ShBP Effect on efficacy of lytics in ShockDog dataLAD occlusion by thrombusHypotension induced by phlebotomyPrewittJACC 1994; 23:784BP Effect on

17、efficacy of lyticAny Randomized Trials ofThrombolysis in Cardiogenic Shock?Most thrombolytic trials specifically excluded patients in cardiogenic shockThe only large placebo-controlled thrombolytic study specifically examining Pts. presenting with shock was GISSI-1Streptokinase = No BenefitAny Rando

18、mized Trials ofThroCombined IABP and ThrombolysisGUSTO-I:IABP in 62 of the 310 lytic Rxd Pts. in shockObservational Data:Combined IABP and ThrombolysisCombined IABP and ThrombolysisKovack, et. al., JACC 2019Stomel, et. al., Chest 1994Two retrospective observational series from community hospitals:Im

19、proved survival from combination Rx.Combined IABP and ThrombolysisCombined IABP and ThrombolysisObservational Data from SHOCK Registery:Combined IABP and ThrombolysisCombined IABP and Thrombolysis -Barron, et.al., AHJ June 2019 -National Registry of MI-2, Data base-21,178 pts. Presenting with or dev

20、eloping post-MI shock-32% Received IABPP Selection BiasP0.001P=NSTTTTIABPPPTCAPPTCombined IABP and ThrombolysisAccompanying Editorial by Magnus Ohman, and Judith Hochman:“Although, there is a wealth of physiologic and outcomes data to support the use of early IABP therapy in cardiogenic shock (in co

21、njunction with lytics), randomized trials are clearly needed.”Combined IABP and ThrombolysisCombined IABP and ThrombolysisThe only randomized trial on the subject:Thrombolysis and Counterpusion to Improve Cardiogenic Shock Survival (TACTICS): Results of a Prospective Randomized Trial. Magnus Ohman,

22、et.al., Circulation Oct. 2000 Supp. AbstractCombined IABP and ThrombolysisTACTICSST elevation MI patients, presenting within 12 hours of Sx, and Cardiogenic shock57 Patients were randomizedThrombolyticTherapy aloneThrombolyticTherapy +IABPTACTICSST elevation MI patientTACTICSThe primary endpoint of

23、6 month mortality was not statistically significant, P=0.3Subgroup analysis: For KILLIP classes III and IV, P=0.07TACTICSThe primary endpoint ofPATIENT IS IN SHOCK w/ ST elevations, and 12 hrs Sx onsetIABPPressorsMay increase the efficacy of LyticsAdministration of Lytics should not be delayed in an

24、ticipation of placement of IABPdespite lack of randomized data proving efficay. If EARLY REVASCULARIZATION is not to be pursued: PATIENT IS IN SHOCK w/ ST elevSHOCK TrialWhether EARLY REVASCULARIZATION improves survival among patients with cardiogenic shock?SHOCK TrialSHOCK Trial302 Pts. with ST ele

25、vation (or new LBBB) and cardiogenic shockImmediate Revascularization (CABG/PTCA)Late revascularization (if indicated) deferred for at least 54 hoursWithin 36 hrs. of MI onsetWithin 12 hrs. of Shock onsetSHOCK Trial302 Pts. with ST elSHOCK Trial: Primary end point, 30 days mortalityDiff.=9% P=0.1147

26、%56%MortalityDiff.=13% P=0.02750%63%52.4%66.4%Diff.=14%P0.02Revasc.Med RxSHOCK Trial: Primary end poinSHOCK TrialWhy wasnt the Primary end-point met?Low mortality in the initial medical mgt gp.High rates of IABP use, 86%TT use, 63%Delayed revasculariztion, 21%Median of 104 hrspost randomization30 da

27、ys mortality47%56%SHOCK TrialWhy wasnt the PriSHOCK Trial: Subgroup analysis, Age less than 75Revasc.Med RxP=0.02CI1.0P=0.002CI1.0Mortality45%65%41%56%66.7%48.4%P0.02CI 1.0)6 months( CI 1.0) 12 months, no difference in outcomeSHOCK Trial: What to do with What to do with Pt.s older than 75SHOCK Regis

28、try results is in contrast to the SHOCK Trial findings in this subgroup.Those older than 75 y.o., selected to undergo ERV had a survival advantage.Case by case assessment in this population, and not across the board exclusion is called for.What to do with Pt.s older thaRole of IIb/IIIa Inhibitors an

29、d Stents in Cardiogenic ShockSHOCK Trial:Revascularization(N=152)Medical Treatment(N=150)IIb/IIIa Antagonist41.7%25%Stent Placement35.7%52.3%Role of IIb/IIIa Inhibitors anRole of IIb/IIIa inhibitors in Cardiogenic Shock Retrospective subgroup analysis from the PURSUIT trialHassade, et.al., JACC, 200

30、0 Randomization to eptifibatide did not affect the incidence of shockPatients randomized to eptifibatide who developed shock had a significantly reduced incidence of death at 30 daysA possible mechanism of benefit is relief of microvascular obstructionRole of IIb/IIIa inhibitors inRole of IIb/IIIa I

31、nhibitors and Stents in Cardiogenic ShockLong-Term Mortality Benefit With the Combination of Stents and Abciximab for Cardiogenic Shock Complicating Acute Myocardial InfarctionCoronary Artery DiseaseChan, Albert W. MD, MS; Chew, Derek P. MBBS; Bhatt, Deepak L. MD; Moliterno, David J. MD; Topol, Eric

32、 J. MD; Ellis, Stephen G. MDAJC Jan. 15, 2019Role of IIb/IIIa Inhibitors anRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockSingle center, non-randomizedData collected: Jan.1993 and June 2000 Thirty month follow-up available96 Pt.s w/ Cardiogenic ShockStent + ReoproN=27Stent OnlyN=14PTCA+R

33、eoproN=18PTCA OnlyN=37Role of IIb/IIIa Inhibitors anRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockThirty day Mortality Rates (%)Stent+ReoproStent OnlyPTCA+ReoproPTCA OnlyAbsence of Stent use: HR 2.39, 95% CI 1.22 to 4.67, p = 0.01Absence of Abciximab use: HR 1.95, 95% CI 1.03 to 3.71, p

34、 = 0.04On Univariate analysis:EF =30% HR 3.44, 95% CI 1.35 to 8.78, p = 0.01Role of IIb/IIIa Inhibitors anRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockUse of Stents29% Absolute mortality reduction1 additional life saved for each 3-4 treated Patients.Abciximab +Stenting10% Absolute mort

35、ality reduction 1 additional life saved for each10 patients treated. At 30 monthsRole of IIb/IIIa Inhibitors anRole of IIb/IIIa Inhibitors and Stents in Cardiogenic Shock Results of Primary Percutaneous Transluminal Coronary Angioplasty Plus Abciximab With or Without Stenting for Acute Myocardial In

36、farction Complicated by Cardiogenic ShockCoronary Artery DiseaseGiri, Satyendra MD, MPH, MRCP; Mitchel, Joseph DO; Azar, Rabih R. MD, MSc; Kiernan, Francis J. MD; Fram, Daniel B. MD; McKay, Raymond G. MD; Mennett, Roger MSc; Clive, Jonathan PhD; Hirst, Jeffrey A. MD, MSAJC, 15 January 2019 .Role of

37、IIb/IIIa Inhibitors anRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockThis was a nonrandomized, prospective observational study. 113 (13.9%) were diagnosed with cardiogenic shock from 8/95 to 8/99.Role of IIb/IIIa Inhibitors anRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockNo

38、ReoproWith ReoproRole of IIb/IIIa Inhibitors anRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockMultivariate AnalysisRole of IIb/IIIa Inhibitors anRole of IIb/IIIa Inhibitors and Stents in Cardiogenic ShockSpeculation:Greater use of Abxicimab, and Stents in the SHOCK Trial may well have resulted in a positive primary endpoint.The age cutoff of 75 may or may not have retained its significance vis-vis increased