Download Cardiac Pulmonary Edema and Cardiogenic Shock

ACC/AHA Guidelines
Cardiac Pulmonary Edema
and Cardiogenic Shock
胡為雄
Stroke Volume
Frank-Starling Law
End-Diastolic Pressure
“In the normal heart, the diastolic volume (preload) is the principal force that
governs the strength of ventricular contraction.”
Otto Frank and Ernest Starling
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ACC/AHA Guidelines
Pulmonary Edema Flow
P : hydrostatic pressures
π : oncotic pressures
Kf : permeability constant of vessel wall
δ : reflection coefficient
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Pulmonary Edema
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ACC/AHA Guidelines
HEMODYNAMIC CHANGES
PROGRESSIVE LEFT HEART FAILURE
Hours
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Cardiogenic Shock
• Cardiogenic shock (CS) is a state of
inadequate tissue perfusion due to cardiac
dysfunction, and complicates 7-10% of
cases of acute myocardial infarction
• Without treatment, cardiogenic shock is
associated with a 70-80% mortality rate,
and is the leading cause of death in
patients hospitalized for an acute
myocardial infarction
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ACC/AHA Guidelines
Classic Criteria for Diagnosis of Cardiogenic Shock
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Systemic Hypotension
systolic arterial pressure < 80 mmHg
Persistent Hypotension
at least 30 minutes
Reduced Systolic Cardiac Function
Cardiac index < 1.8 x m²/min
Tissue Hypoperfusion
Oliguria, cold extremities, confusion
Increased Left Ventricular Filling
Pulmonary capillary wedge pressure > 18 mmHg
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Frequency of CS Has Remained Steady Over Time
Frequency of Cardiogenic Shock : 7-9%
NRMI STEMI Registry
N=25,311
Babaev et al JAMA 2005 294:448
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ACC/AHA Guidelines
Pathophysiology of Cardiogenic Shock
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Causes of Cardiogenic Shock
SHOCK Trial and Registry (N=1160)
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Ventricular Septal Rupture
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Ventricular Septal Rupture
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Incidence
Timing
PE
Thrill
Echo
PA cath
1-2%
2-5 d p MI
murmur 90%
common
shunt
O2 step up > 9%
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Echo
IABP
Inotropic Support
Surgical Timing is
controversial, but
usually < 48 h
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ACC/AHA Guidelines
Free Wall Rupture
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Free Wall Rupture
• Incidence: 1-6%
• Occurs during first week after MI
• Classic Patient: Elderly, Female,
Hypertensive
• Early thrombolysis reduces incidence but
Late increases risk
• Echo: pericardial effusion,
PA cath: equal diastolic pressure
• Treat with pericardiocentesis and early
surgical repair
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ACC/AHA Guidelines
Acute Mitral Regurgitation
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Management of Acute MR
• Incidence: 1-2%
• Echo for Differential Diagnosis:
– Free-wall rupture
– VSD
– Infarct Extension
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PA Catheter: large v wave
Afterload Reduction
IABP
Inotropic Therapy
Early Surgical Intervention
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Right Ventricular Infarction: Diagnosis
Clinical findings:
Shock with clear lungs,
Elevated JVP
Kussmaul sign
ECG:
ST elevation in R sided leads
Echo:
Depressed RV function
V4R
Modified from Wellens. N Engl J Med 1999;340:381.
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ACC/AHA Guidelines
Management of RV Infarction
• Cardiogenic Shock secondary to RV Infarct has better
prognosis than LV Pump Failure
• IV Fluid Administration
• IABP
• Dobutamine
• Maintain A-V Synchrony
• Mortality with Successful Reperfusion = 2% vs.
Unsuccessful = 58%
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The Shock Trial has been the most important study
for management guidelines in patients with
cardiogenic shock
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Hochman et al NEJM 1999;341:625
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ACC/AHA Guidelines
The SHOCK Trial (N=302)
Randomization from Apr 1993-Nov 1998
Primary Endpoint: Overall 30 day mortality
Seconday Endpoints: 6 month and 1 year mortality
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SHOCK Trial
Primary and Secondary Endpoints
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Mortality (%)
P= .027
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P=.11
63.1%
56.0%
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50.3%
46.7%
Immediate
Revascularization
Strategy
Medical Stabilization
as an Initial Strategy
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0
30 Days
Primary Endpoint
6 months
Secondary Endpoint
Hochman et al, NEJM 1999; 341:625.
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ACC/AHA Guidelines
PCI v. CABG in the Shock Trial
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SHOCK Trial: Age < 75
Immediate Revascularization Strategy
Medical Stabilization as an Initial Strategy
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80
P < .01
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P < 0.002
65.0%
60
56.8%
%
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41.4%
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30 Day Mortality
44.9%
6 Month Mortality
Hochman et al, NEJM 1999; 341:625.
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ACC/AHA Guidelines
SHOCK Trial: Age > 75
Immediate Revascularization Strategy
Medical Stabilization as an Initial Strategy
P < 0.003
P < .01
80
80
79.2%
75.0%
60
%
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56.3%
53.1%
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40
20
20
0
0
30 Day Mortality
6 Month Mortality
Hochman et al, NEJM 1999; 341:625.
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NRMI Revascularization Rates Over Time By Age
• Mortality rates also decreased for those pts undergoing PCI
• Use of PCI increased from 27.4% to 54.4% (p < 0.001)
• Use of PCI was the strongest independent predictor of a lower inhospital mortality (AOR 0.46; p < 0.001)
Babaev et al JAMA 2005 294:448
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ACC/AHA Guidelines
6 Yr Outcome of SHOCK All Patients
Hochman et al JAMA 2006; 295:2511
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Cardiogenic Shock
NRMI STEMI Registry (N=25,311)
Mortality Rates Over Time
60.3%
47.9%
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P < 0.001
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• Age, 69.4 years
• Women, 42.6%
• Hypertension, 49.7%
• Diabetes, 27.2%
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• Prior MI, 23.2%
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• Prior CHF, 15.2%
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• Prior PCI, 9.1%
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1995
2004
• Prior CABG, 12.2%
Babaev et al JAMA 2005 294:448
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ACC/AHA Guidelines
Prognosis Is Worse With NSTEMI
likely related to the extent of underlying disease
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Multivariable Mortality Predictors
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Increasing age 1,2,3,4,7 and female gender7
Lower left ventricular ejection fraction 4,6
Chronic renal insufficiency7
Initial6 and Final TIMI Flow grade 14
Lower systolic blood pressure 1
Diabetes mellitus 5
Prior MI 2
Increasing time from symptom onset to PCI 1,4
Total Occlusion of the LAD 7Mitral regurgitation
Multivessel PCI (p = 0.040) 1,4,6
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4 Zeymer
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Webb et al JACC 2003;42:1380
Sutton Heart 2005;91:339
3 Tedesco AHJ 2003:146; 472
7 Klein et al AJC 2005; 96:35
et al EHJ 2004;25:322
Tedesco JV Mayo Clin Proc 2003; 78:561
6 Sanborn JACC 2003:42; 1373
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ACC/AHA Guidelines
ACC/AHA Guidelines for Cardiogenic Shock
Class I
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Early revascularization, either PCI or CABG, is
recommended for patients < 75 years old with ST
elevation or new LBBB who develop shock unless further
support is futile due to patient’s wishes or unsuitability for
further invasive care.
Fibrinolytic therapy should be administered to STEMI
patients with cardiogenic shock who are unsuitable for
further invasive care and do not have contraindications
for fibrinolysis.
Echocardiography should be used to evaluate
mechanical complications unless assessed by invasively
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ACC/AHA Guidelines for Cardiogenic Shock
Class IIa
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Pulmonary artery catheter monitoring can be useful for the
management of STEMI patients with cardiogenic shock.
2.
Early revascularization, either PCI or CABG, is reasonable for
selected patients > 75 years with ST elevation or new LBBB who
develop shock < 36 hours of MI and who are suitable for
revascularization that is performed < 18 hours of shock.
Patients with good prior functional status who agree to invasive care may be
selected for such an invasive strategy.
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CARDIOGENIC SHOCK
MECHANICAL SUPPORT
• IABP Counterpulsation
• ECMO
• Ventricular assist devices
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IABP
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IABP support was associated with a ↓ in mortality:
* NRMI-2 with lysis, from 67% to 49%
* SHOCK Trial, from 63% to 47%
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ACC/AHA Guidelines
Contraindications to IABP
•Significant aortic regurgitation
•Abdominal aortic aneurysm
•Aortic dissection
•Uncontrolled septicemia
•Uncontrolled bleeding diathesis
•Severe bilateral peripheral vascular disease uncorrectable
by peripheral angioplasty or cross-femoral surgery
•Bilateral femoral-popliteal bypass grafts for severe
peripheral vascular disease
Grossman’s 2000
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ACC/AHA Guidelines for Cardiogenic Shock
Class I
1. IABP is recommended for STEMI patients when
cardiogenic shock is not quickly reversed with
pharmacological therapy. The IABP is a
stabilizing measure for angiography and prompt
revascularization.
2. Intra-arterial monitoring is recommended for the
management of STEMI patients with cardiogenic
shock.
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ACC/AHA Guidelines
ECMO
extracorporeal membrane oxygenation
extracorporeal life support
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ECMO
• Short-term cardiopulmonary support
• Buy time to decide the next step
– Recovery
– Transplantation
– Long-term device (ventricular assist device)
– Operation (CABG, pulmonary embolectomy,..)
– Give-up
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ACC/AHA Guidelines
Ventricular Assist Devices
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Ventricular Assist Devices
• RVAD, LVAD, BiVAD
• Nonpulsatile pump
• Placed in parallel with RV, LV or both
ventricles
• Adjusted to provide total systemic flow of
2-3 L/min/M2
• Complications in 50% of patients:
– bleeding
– systemic embolism
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ACC/AHA Guidelines
謝謝
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