Καξδηαθή αλεπάξθεηα Heart...

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How to treat the patient with acute myocardial infarction and…

Καξδηαθή αλεπάξθεηα

Heart failure

Γεώξγηνο Χάραιεο, Επίθνπξνο Καζεγεηήο Καξδηνινγίαο

George Hahalis, Assistant Professor of Cardiology

Ρίνλ, Πάηξα - Rio, Patras

How to treat post-MI heart failure

Outline…

•What do we know (registries-cohort studies)?

•Pharmaco-invasive strategies and treatment for:

•prevention-limitation of MI size

•post-MI therapy of LV dysfunction - mechanical complications

•Guidelines

•How should we treat these patients (case-scenarios)


Outline…



•Prevention-limitation of MI size

•post-MI therapy of LV -mechanical complications

dysfunction

•Guidelines


Heart Failure and Myocardial infarction

i) Timing of development

•Discharge Dx: MI in 1998 (N=898 pts); Follow-up until 2005

(Torabi A. Eur Heart J 2008;29:859)

ii) Causes of death

How to treat the patient with acute myocardial infarction a & heart failure

-9 %

Cath B-blockers

-15 %

HF vs. no HF pts

STEMI NSTEMI UA No HF

& HF & HF & HF

Mortality

In-Hospital

12 % 11 %

3.0 %

17 %

GRACE registry16 166 patients analyzed: 13 707 pts

without prior HF or shock at presentation

Swedish registry1993-2004 trends for a first

episode of HF within 3 years in

175216 pts 35–84 yo & first MI

Decrease of HF risk

by 4%/year

2002-04

1993-95

(Shafazand M. Eur Heart J 2011;13:135) (Steg PG. Circulation 2004;109:494)


TIMI Risk Score in STEMI (but not in Non-STEMI) &

GRACE Score Include Hemodynamic Instability

65-74 years

75 years and older

History of angina, diabetes, or hypertension

•Admission systolic blood pressure <100 mm Hg

•Admission heart rate >100 beat/min

•Admission Killip class II to IV

Admission weight <67 kg

Anterior infarction or LBBB

Time to reperfusion therapy >4 hours among reperfused pts

Older age

•Killip class

•Systolic BP

ST-segment deviation

Cardiac arrest during presentation

Serum creatinine level

Positive initial cardiac biomarkers

•Heart rate

TIMI score

In STEMI

GRACE score



Outline…





dysfunction

•Guidelines


Less Incident Heart Failure by Limiting Total Ischemic Time

EMS Transport

Onset of

symptoms of

STEMI

9-1-1

EMS

Dispatch

EMS on-scene• Encourage 12-lead ECGs.

• Consider prehospital fibrinolytic if

capable and EMS-to-needle within

30 min.

GOALS

PCI

capable

Not PCI

capable

Hospital fibrinolysis:

Door-to-Needle

within 30 min.

Inter-

Hospital

Transfer

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Patient EMS Prehospital fibrinolysisEMS-to-needle

within 30 min.

EMS transportEMS-to-balloon within 90 min.

Patient self-transport

Hospital door-to-balloon

within 90 min.

Dispatch

1 min.

5

min.

8

min.

Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December 10, 2007. Available at

http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001. Figure 1.


http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001

Conservative Rescue PCI

treatment

12.7 %

(54/424)

-27%

17.8 %

(76/427) P=0.05

Incident heart failure

Rescue PCI vs. Conservative Therapy After Failed Thrombolysis

(Wijeysundera HC Metaanalysis. JACC 2007;49:422)


RR=0.62 (P=NS)

RR=0.61

0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6

Lower Higher

Post-discharge Mortality Risk

PCI vs No Revascularization

CABG vs No revascularization

Heart Failure in Non-STEMI: Post-discharge Mortality

Depending on In-hospital Revascularization Status

(Steg PG . Circulation 2008;118:1163)


ACE-Ihhibitors vs. Placebo After Myocardial Infarction(N=5966 pts in three trials with average follow-up 35 months)

Placebo Yes ACEI Placebo Yes ACEI Placebo ACEI

23 %

29 %-26%

29 %

23 %

-26%29 %

23 %

-26%29 %

Mortality

23 %

-26%29 %

Readmissions for HF

12 %

-27%16%

Reinfarction

10.5%

-20%13 %

(Flather MD, Yusuf S et al. Lancet 2000;355:1575 & Lee VC et al. Ann Intern Med 2004;141:693)

•2 RCT’s (OPTIMAAL-VALIANT)

of ACE-Inhibitors vs ARBs for high-risk post-

MI patients: No differences in all-cause

mortality or HF hospitalization

23 %


Placebo β-blocker Placebo β-blocker Placebo β-blocker Placebo β-blocker

9.0 %-36%

GMP, Metoprolol(9% with HF; 3 mo. FU)

5.7 %

NNT, Timolol(34% with HF;17 mo. FU)

16 %

11 %

-35% -23%

CAPRICORN,

ACEI+Carvedilol (17 mo. FU)

15.3 %

12 %

BHAT, Propranolol

(14% with HF;25 mo. FU)

-25%

Hjalmarson Å, Lancet 1981; ii:823

Norwegian MS Group NEJM 1981;304:801

BHAT Research Group JAMA 1982;247:1707

CAPRICORN, Lancet 2001;357:1385

Eur J Heart Fail 2002;4: 501

Total

mortality

Beta-blockers vs. Placebo Post-MI & Impaired Systolic Function


-15%

Placebo Epleronone Placebo Epleronone

(+ Optimal Medical Treatment: ACEI/ARB - β-Blockers - Revascularization)

26.7 %

30 %

14.4 %

16.7 %

•6 632 patients with AMI (in prior 3-14 days) + LVEF<40% + Heart Failure or DM w/o HF

CV Death-Repeat hospitalization

Mortality

P=0.008

P=0.005-17%

(N Engl J Med 2003;348:1309)

EPHESUS Trial (Epleronone in post-MI Heart Failure)


Clopidogrel: No (n=2525)

Clopidogrel: Yes (n=2525)

Clopidogrel: No (n=3046)

Clopidogrel: Yes (n=3046)

9.7%

9.4 %

Patients with heart failure P=0.002

Patients without heart failure P=NS

Heart Failure in STEMI Patients Without PCI:

Increased Mortality in Low Clopidogrel Use

(Bonde L. JACC 2010;55:1300)

32 %

28 %

Pro

pensity m

atc

hed c

ohort

s


Randomized to emergency revascularization (n=152, 87% revascularized, 55% with PCI),

or medical stabilization (n=150; 2.7% revascularized); IABP in 86%

Median time to the onset of shock: 5.6 hours; mean EF: 30%;

The SHOCK trial

(Sanborn TA, JACC 2000;36:1123)

Time from MI to 73

randomization < 6 hr

Time from MI to 227

randomization > 6 hr

Subgroup No of pts

0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6

Odds Ratio

50

%

100

%

Conserv group

< 75 years >75 years

Revasc group

P=0.003

6-month mortality

Revascularization

better

Conservative

better

(NEJM 1999)

The SHOCK Registry: Mortality in 884 patients

•No thrombolysis, no IABP: 77%

•Thrombolysis: 63%

•Thrombolysis+IABP:47%


should have been excluded

Vasovagal reaction

Pharmacological hypotension

Hypovolemia

Arrhytmias

Tamponade

Electrolyte disturbances

Differential diagnosis of cardiogenic shock

•Extensive LV myocardial damage (78% in the SHOCK registry)

•RV infarction (2.8% in the SHOCK registry)

•Mechanical complications

•Ventricular septal rupture

•Papillary muscle/tip rupture: acute MR

•Free wall rupture-tamponade

(Hochman JS. JACC 2000;36:1063 (3 Suppl A) & STEMI guidelines ESC 2008)

(11% in the

SHOCK registry)


Devices in Cardiogenic Shock

IABP Versus LVAD IABP Versus No-IABP

3 Randomized Trials 11 Non-Randomized Trials

(n= 100) (n=10439)

Bleeding risk

30-days mortality

P<0.05

P=NS

P=NS

Relative Risk

0 10

Favors LVAD Favors IABP

Better Less

Hemodynamice Bleeding

RR=2.35 (1.4-3.9)

Leg ischemia

(+0.05 to +0.15)

-0.5 0 +0.5

Favors IABP Favors Non-IABP

30-day Mortality: Risk difference

No reperfusion(Moulopoulos)

-0.3

-0.2

(-0.5 to -0.1)

(-0.3 to -0.1)Thrombolysis

Primary PCI+0.1

(Sjauw KD. EHJ;2009;30:459)

(Cheng JM. EHJ;2009;30:2102)



Outline…


Which is our armamentarium?




dysfunction

•Guidelines


O2, Diuretics, ACI/ARB, Epleronone

Early revascularization (Killip III,IV)

IABP, ventilatory support (Killip III,IV)

IIb

IIb

IIa

IIa

IIa

I

I

I

Emergent cath (<2h): UA/NSTEMI & Killip II-IV

LVAD (Killip IV)

Dopamine (Killip III,IV)

Dobutamine (Killip III,IV)

Right heart catheterization (Killip III,IV)

ESC Guidelines: Heart failure (2008) & Myocardial Revascularization (2010)


Pharmacological Treatment

Initial dosage(mg)

Target dosage(mg)

•CaptoprilSAVE, ISIS-4, CHINESE 6.25 - 12.5 @ 2h 50X3

•LisinoprilGISSI-3 5 10

•ZofenoprilSMILE 7.5X2 30X2

•RamiprilAIRE 2.5X2 5X2

•TrandolaprilTRACE 0.5 5

•LosartanOPTIMAAL 12.5 50

•ValsartanVALIANT 20 160X2

•EplerononeEPHESUS 25 50

•CarvedilolCAPRICORN 3.125X2 25X2


(STEMI focus update AHA/ACC 2009 & UA/NSTEMI guidelines ESC 2011)

Recommendations Class Level

•Thrombolysed STEMI in nonPCI hospital and Killip II or III:Preparatory antithrombotic (anticoagulant + antiplatelet) regimen before and during

patient transfer to the cath lab

Transfer to a PCI capable facility as soon as possible

IIa B

•Failed or uncertain thrombolysis result:

Rescue PCI immediately

IIa B

•Severe, persisting LV dysfunction > one month post MI:

Cardiac resynchronization therapy + ICD

IIa B

How to treat the patient with acute myocardial infarction a & heart failureHow to treat the patient with acute myocardial infarction a & heart failure

Hemodynamically

remaining

instability

LVAD or BiVAD

Not weaning

No neurological deficit

(Myocardial revascularization guidelines ESC 2010)

Ultra compact mobile ECMO-

Cardiohelp circuit-

23 F(right FV)

17 F (left FA)

17 F

(jugular

vein)

ECMO support


http://icvts.ctsnetjournals.org/content/vol12/issue6/images/large/978fig2.jpeg


Outline…


Which is our armamentarium?




dysfunction

•Guidelines

•How should we treat these patients (# 6 case-scenarios)

Urgent cath

Stabilized

ACEI/ARB

Oral β-blocker

Epleronone

DAPT *Anticoagulation

Echo

Killip II or III

(or Flush PE)

NSTEMI

ST-Depression

New onset acute HF

cTroponin: +

* Dual antiplatelet therapy

Heart Failure Killip II or III & NSTEMI

Ventouri mask/CPAP, Loop diuretics, Nitrates i.v.

# 1How to treat the patient with acute myocardial infarction a & heart failure

Killip III

NSTEMI

ST-Depression

DAPT

Anticoagulation

Echo (EF=35%)

ACEI

Oral b-blocker

Epleronone

Killip III

NSTEMI

ST-Depression

DAPT

Anticoagulation

Echo (EF=35%)

Killip III

NSTEMI

ST-Depression

DAPT

Anticoagulation

Echo (EF=35%)

Killip III

NSTEMI

ST-Depression

ACEI

Oral b-blocker

Epleronone

DAPT

Anticoagulation

Echo (EF=35%)

Killip III

NSTEMI

ST-Depression

ACEI

Oral b-blocker

Epleronone

DAPT

Anticoagulation

Echo (EF=35%)

Killip III

NSTEMI

ST-Depression

ACEI

Oral b-blocker

Epleronone

DAPT

Anticoagulation

Echo (EF=35%)

Killip III

NSTEMI

ST-Depression

Primary PCI

DAPT *

Anticoagulation

+IABP

Killip II or III

e.g., Anterior STEMI

PCI available

(D2B< 90min)

Heart Failure Killip II or III & STEMI (1)

Intubation/Ventilatory support, Loop diuretics, Nitrates i.v

ACEI/ARB,

Oral β-blocker, Epleronone

RST/ICD ++



DAPT

Anticoagulation

Echo (EF=35%)

ACEI

Oral b-blocker

Epleronone

DAPT

Anticoagulation

Echo (EF=35%)

DAPT

Anticoagulation

Echo (EF=35%)

ACEI

Oral b-blocker

Epleronone

DAPT

Anticoagulation

Echo (EF=35%)

ACEI

Oral b-blocker

Epleronone

DAPT

Anticoagulation

Echo (EF=35%)

ACEI

Oral b-blocker

Epleronone

DAPT

Anticoagulation

Echo (EF=35%)

Thrombolysis

DAPT *

Anticoagulation

+IABP

Killip II or III

e.g., Anterior STEMI

PCI NOT available

(D2B > 90min)

Transfer

Secondary PCI

ACEI/ARB, Oral β-blocker, Epleronone

RST +

Heart Failure Killip II or III & STEMI (2)


Intubation/Ventilatory support +, Loop diuretics, Nitrates i.v.


Primary PCI better than

Thrombolysis

DAPT

Anticoagulation

Preload increase

Inotropes

Inferior STEMI

Hypotension, no rales,

Increasd JVP

DD: Tamponade,

Pulm Embolism

Predominant RV Infarction

Echo (Rule out mechanical complications)

Intubation/Ventilatory support +, NO Nitrates (!)

# 4

70 year old woman;

Failed primary PCI of the RCA on

18/10/2011;

Death on 19/10/2011


Secondary (rescue)

multivessel

PCI

Transfer

Thrombolysis

DAPT

Anticoagulation

IABP if possible

Cardiogenic

Shock

PCI NOT

Available

Intubation/Ventilatory support, Loop diuretics, Inotropes

Cardiogenic Shock (1)

Echo (Rule out mechanical complications)

ACEI/ARB,

Oral β-blocker,

Epleronone

RST



Primary,

multivessel PCI

or emergent CABG

DAPT

Anticoagulation

IABP

Cardiogenic

Shock

PCI

available

Intubation/Ventilatory support, Loop diuretics, Inotropes

Echo (Rule out mechanical complications

ACEI/ARB, Oral β-blockers, Epleronone,

CRT


Mild systolic murmur; Emergent operation;

Death on 19/10/2011

33 year old man, Primary PCI of the LCx on 16/10/2011



# 6

to treat the patient with acute myocardial infarction a & heart failure

Thank you for

your attention

Εσταριστώ για

την προσοτή σας

to treat the patient with acute myocardial infarction a & heart failure

Back-up slides

P<0.005

P<0.005

1.0 %

3.0 %

5.0 %

2.0 %

BNP<80 pg/ml(n=1251)

BNP>80 pg/ml(n=1274)

30 days 10 months

Recurrent heart failure

0 2.5 5

Έηε παξαθνινύζεζεο

Mortality(n=609)

BNP in ACS’s, Recurrent Heart Failure & Mortality

(De Lemos JA. NEJM 2001;345:1014) (Omland T. Circulation 2002;106:2913)

Killip I

Killip II

BNP, low

BNP, high

BNP, low

BNP, high

•Centrifugal pump (Vortex CN80; BioMedicus, Medtronic,

Englewood, CA)

•Pressure-controlled biocompatible heparin-coated polypropylene

Oxygenator (Affinity; Omnis AOT GmbH, Bad Oyenhausen,

Germany [membrane surface area of 2.5 m2 and a maximum

blood flow of 7.0 L/min]) and

•Heat exchanger

ECMO support

•ECMO flow gradually increased to 4.5 L/min

•If renal insufficiency present: a hemofiltration unit integrated into

the circuit

•Arterial return cannula (15F to 21F) inserted directly into the

ascending aorta -the femoral artery (percutaneously or through a

6-mm prosthesis) -the subclavian artery

•Venous drainage (21F to 28F) inserted either directly into the RA

or into the femoral vein with placement of the tip just proximal to

the right atrium

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