Defining Cardiogenic Shock: Fundamentals of...

Defining Cardiogenic Shock: Fundamentals of Hemodynamics

GREG WOOD, MD, MSOCTOBER 19, 2019

DISCLOSUREGregory Wood, MD

Consulting, Speaking & Teaching: Abbott

DISCLOSURES

• Consulting and teaching: Abbott

• I am a Mechanical Engineer

OVERVIEW

• Define cardiogenic shock

• Initial assessment

• Review basic hemodynamic parameters in cardiogenic shock

• Basic hemodynamics as a guide to initial treatment

• Important hemodynamic parameters to guide temporary mechanical support

IS MY PATIENT IN CARDIOGENIC SHOCK?Patient A Patient B

CARDIOGENIC SHOCK: A DEFINITION

• Systolic blood pressure < 90 mmHg for more than 30 minutes

• Evidence of end-organ hypoperfusion

• Lactate > 2 mmol/L

INITIAL ASSESSMENT

PRE-CARDIAC CATH LAB ASSESSMENT

• Vital signs• Low blood pressure (SBP < 90, MAP < 55)• Narrow pulse pressure• Tachycardia• Hypoxia


• Vital signs

• Physical exam• Cool extremities• Elevated JVP• Edema• Rales• S3


• Vital signs

• Physical exam

• Laboratory data• Comprehensive metabolic panel (end-organ perfusion)• Lactic acid• Troponin• Central access -> ”mixed venous oxygen saturation”• ABG


• Vital signs

• Physical exam

• Laboratory data

• EKG• Ischemia/infarct• Arrhythmia





• Fick cardiac index < 1.8 L/min/m2 (or < 2.2 L/min/m2 on inotropes)

• Pulmonary capillary wedge pressure > 15 mmHg*

BASIC HEMODYNAMIC ASSESSMENT

ROLE OF HEMODYNAMICS ASSESSMENT

• Confirm cardiogenic shock

WHICH HEMODYNAMIC PARAMETERS? CI

Eur J Heart Fail 2003;5:443-451.

WHICH HEMODYNAMIC PARAMETERS? PCWP


WHICH HEMODYNAMIC PARAMETERS? CPI

• How can we better represent cardiac contractility? 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 = 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 × 𝐹𝐹𝐹𝐹𝑃𝑃𝑃𝑃



• Cardiac power output (CPO):

𝐶𝐶𝑃𝑃𝐶𝐶 =𝑀𝑀𝑀𝑀𝑃𝑃 × 𝐶𝐶𝐶𝐶

451(W)



• Cardiac power output (CPO):


451• Cardiac power index (CPI):


451

(W)

(W/m2)

CPI CAN HELP TO PROGNOSITICATE AS WELL

JACC 2004;44:340-348.

CPO ≤ 0.53 predicts in hospital mortality

CPI THRESHOLD TO DEFINE CARDIOGENIC SHOCK







• Pulmonary capillary wedge pressure > 15 mmHg*






• Pulmonary capillary wedge pressure > 15 mmHg

• Cardiac power index < 0.33 W/m2 (CPO < 0.6 W)

*

ROLE OF HEMODYNAMICS ASSESSMENT

• Confirm cardiogenic shock

• Define treatment modalities• Inotropes• Vasopressors• Vasodilators• Diuretics• Temporary Mechanical Support

TREATMENT OF CARDIOGENIC SHOCK

INOTROPES VASODILATORS DIURETICS VASOPRESSORS

TEMPORARY MECHANICAL SUPPORT

PRELOAD (FILLING PRESSURES)

• Is the right atrial pressure elevated?

RA = 12



RA = 12

• Is the pulmonary capillary wedge pressure elevated?

PCWP = 19



RA = 12


PCWP = 19

• What is the relationship between RA and wedge pressure?

RA/PCWP = 63%



RA = 12


PCWP = 19


RA/PCWP = 63%

DIURETICS



RA = 5


PCWP = 19


RA/PCWP = 26%

DIURETICS



RA = 5


PCWP = 19


RA/PCWP = 26%

VASODILATORS

RA TO PCWP RELATIONSHIP

• If both RA and PCWP are elevated in proportion (RA/PCWP > 50%)• Patient will likely be responsive to diuretics

• PCWP is elevated out of proportion to RA (RA/PCWP < 50%)• Typically more responsive to afterload reduction or LV unloading• Diuresis is less likely to effective and more likely to cause renal injury

AFTERLOAD (VASCULAR RESISTANCE)

• Vascular resistance is the pressure gradient across the circuit divided by the flow through the circuit

• Systemic vascular resistance (700-1500 dynes・ sec・cm-5)

𝑆𝑆𝑆𝑆𝑆𝑆 =𝑀𝑀𝑀𝑀𝑃𝑃 − 𝐶𝐶𝑆𝑆𝑃𝑃

𝐶𝐶𝐶𝐶× 80

• Pulmonary vascular resistance (< 3 Wood units)

𝑃𝑃𝑆𝑆𝑆𝑆 =𝑚𝑚𝑃𝑃𝑀𝑀 − 𝑃𝑃𝐶𝐶𝑃𝑃𝑃𝑃

𝐶𝐶𝐶𝐶



𝑆𝑆𝑆𝑆𝑆𝑆 = 𝑀𝑀𝑀𝑀𝑀𝑀−𝐶𝐶𝐶𝐶𝑀𝑀𝐶𝐶𝐶𝐶

× 80 = 85−123.8

× 80 =1536



𝐶𝐶𝐶𝐶=

31 − 193.8

= 3.2




× 80 = 85−123.8

× 80 =1536



𝐶𝐶𝐶𝐶=

31 − 193.8

= 3.2

VASODILATORS




× 80 = 85−123.8

× 80 =1536



𝐶𝐶𝐶𝐶=

31 − 193.8

= 3.2

VASODILATORS INOTROPES




𝐶𝐶𝐶𝐶× 80 =

45 − 123.8

× 80 = 694



𝐶𝐶𝐶𝐶=

31 − 193.8

= 3.2

VASODILATORS




𝐶𝐶𝐶𝐶× 80 =

45 − 123.8

× 80 = 694



𝐶𝐶𝐶𝐶=

31 − 193.8

= 3.2

INOTROPES VASOPRESSORS

HEMODYNAMIC CONSIDERATIONS FOR MECHANICAL SUPPORT

ASSESSMENT FOR RV FAILURE

• Right ventricular stroke work index (RVSWI): < 0.6 predicts RV failure post MCS

𝑆𝑆𝑆𝑆𝑆𝑆𝑃𝑃𝐶𝐶 = 𝑆𝑆𝑆𝑆𝐶𝐶 × 𝑚𝑚𝑃𝑃𝑀𝑀 −𝑚𝑚𝑆𝑆𝑀𝑀

• Pulmonary artery pulsatility index (PAPi): < 1.85 predicts RV failure post MCS

𝑃𝑃𝑀𝑀𝑃𝑃𝑃𝑃 =𝑃𝑃𝑀𝑀𝑆𝑆 − 𝑃𝑃𝑀𝑀𝑃𝑃

𝑆𝑆𝑀𝑀

J Card Fail. 2016;22:110–116.

SUMMARY

• Define cardiogenic shock

• Initial assessment can help to rapidly triage patient

• Hemodynamics play a key role in characterizing patients in cardiogenic shock

• Basic hemodynamics are an useful guide to initial treatment

• Invasive hemodynamics are crucial in the decision process for temporary mechanical support

Defining Cardiogenic Shock: Fundamentals of HemodynamicsDISCLOSUREDISCLOSURESOVERVIEWIS MY PATIENT IN CARDIOGENIC SHOCK?CARDIOGENIC SHOCK: A DEFINITIONINITIAL ASSESSMENTPRE-CARDIAC CATH LAB ASSESSMENTPRE-CARDIAC CATH LAB ASSESSMENTPRE-CARDIAC CATH LAB ASSESSMENTPRE-CARDIAC CATH LAB ASSESSMENTCARDIOGENIC SHOCK: A DEFINITIONBASIC HEMODYNAMIC ASSESSMENTROLE OF HEMODYNAMICS ASSESSMENTWHICH HEMODYNAMIC PARAMETERS? CIWHICH HEMODYNAMIC PARAMETERS? PCWPWHICH HEMODYNAMIC PARAMETERS? CPIWHICH HEMODYNAMIC PARAMETERS? CPIWHICH HEMODYNAMIC PARAMETERS? CPIWHICH HEMODYNAMIC PARAMETERS? CPIWHICH HEMODYNAMIC PARAMETERS? CPICPI CAN HELP TO PROGNOSITICATE AS WELLCPI THRESHOLD TO DEFINE CARDIOGENIC SHOCKCARDIOGENIC SHOCK: A DEFINITIONCARDIOGENIC SHOCK: A DEFINITIONROLE OF HEMODYNAMICS ASSESSMENTTREATMENT OF CARDIOGENIC SHOCKPRELOAD (FILLING PRESSURES)PRELOAD (FILLING PRESSURES)PRELOAD (FILLING PRESSURES)PRELOAD (FILLING PRESSURES)PRELOAD (FILLING PRESSURES)PRELOAD (FILLING PRESSURES)RA TO PCWP RELATIONSHIPAFTERLOAD (VASCULAR RESISTANCE)AFTERLOAD (VASCULAR RESISTANCE)AFTERLOAD (VASCULAR RESISTANCE)AFTERLOAD (VASCULAR RESISTANCE)AFTERLOAD (VASCULAR RESISTANCE)AFTERLOAD (VASCULAR RESISTANCE)HEMODYNAMIC CONSIDERATIONS FOR MECHANICAL SUPPORTASSESSMENT FOR RV FAILURESUMMARY

Defining Cardiogenic Shock: Fundamentals of...

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