Presentazione di PowerPoint - area-c54.it cardiogeno.pdf · ¾Obstruction due to atrial myxoma or...
Transcript of Presentazione di PowerPoint - area-c54.it cardiogeno.pdf · ¾Obstruction due to atrial myxoma or...
CARDIOGENIC CARDIOGENIC SHOCKSHOCK
Antonio Antonio PesentiPesenti
Università degli Studi di Milano BicoccaUniversità degli Studi di Milano Bicocca
Azienda Ospedaliera San Gerardo Azienda Ospedaliera San Gerardo –– Monza (MI)Monza (MI)
Primary myocardial dysfunctionresulting in the inability of the heart to mantain an adeuqte
cardiac output (CO) withsubsequent compromising of
metabolic requirements
From: Civetta et al (eds) Critical Care
DEFINITION (1)
• Decreased cardiac output
• Evidence of tissue hypoxia
• Adequate intravascular volume
DEFINITION (2)
• Reduced CI ( < 2.2 l/min/ m2)
• Sustained hypotension ( BP < 90 mmHG or drop > 30 mmHG for > 30 min)
• WP > 15 mmHg
DEFINITION (3)
• Poor tissue perfusion ( cold clammy skin, altered sensorium, oligo-anuria)
• Hypotension
• Jugular vein fillings, rales
CARDIOGENIC SHOCKClinical Recognition
• In the SHOCK trial: 64% of pts :
• Hypotension; • Ineffective CO ( tachycardia, altered
mentation, oliguria , cold periphery• Pulmonary congestion
Menon V, et al. J Am Coll Cardiol 2000;36:1071–6.
CARDIOGENIC SHOCKClinical Recognition
• In the SHOCK trial: 28% of pts :
• Hypotension• Hypoperfusion• No pulmonary congestion ( silent lung)• WP 21.5 + 6.7 mmHG
Menon V, et al. J Am Coll Cardiol 2000;36:1071–6.
GUSTO I study:30 days mortality model
importance of subjective signs• Dying OR = 1.68
• Dying OR = 1.68
• Dying OR = 2.25
• Altered sensorium
• Cold Clammy Skin
• Oliguria
Independently of objective hemodynamicsFrom Hasdai D, et al. Cardiogenic shock complicating acute myocardial infarction: predictors of death. Am Heart J 1999;138:21–31.
CausesCauses (1)(1)SystolicSystolic dysfunctiondysfunction ((decreaseddecreased contractilitycontractility):):
IschemiaIschemia//MyocardialMyocardial InfarctionInfarctionGlobal hypoxemiaGlobal hypoxemiaMyocarditis (viral, autoimmune, Myocarditis (viral, autoimmune, parasiticparasitic))CardiomyopathiesCardiomyopathies ((hypertrophichypertrophic, , amyloidamyloid))MyocardialMyocardial depressantdepressant drugsdrugs ((egeg, , betabeta--blockersblockers, , calciumcalcium
channelchannel blockersblockers, , antiarrhythmicsantiarrhythmics, , propofolpropofol, , anthracyclineanthracycline) ) MyocardialMyocardial contusioncontusionIntrinsic Depression (Intrinsic Depression (egeg, , hypoxiahypoxia, , acidosisacidosis, , hypocalcemiahypocalcemia, ,
hypophosphatemiahypophosphatemia))
CausesCauses (2)(2)
DiastolicDiastolic dysfunctiondysfunction(increased myocardial (increased myocardial stiffnessstiffness))
IschemiaIschemiaVentricular hypertrophy Ventricular hypertrophy Restrictive cardiomyopathy Restrictive cardiomyopathy Consequence of prolonged hypovolemic or septic shock Consequence of prolonged hypovolemic or septic shock Ventricular interdependence Ventricular interdependence External External compressioncompression byby pericardialpericardial tamponadetamponade
CausesCauses (3)(3)
GreatlyGreatly increasedincreased afterloadafterload
AorticAortic stenosisstenosisHypertrophic cardiomyopathy Hypertrophic cardiomyopathy Dynamic aortic Dynamic aortic outflowoutflow tracttract obstructionobstructionCoarctationCoarctation of the aorta of the aorta MalignantMalignant hypertensionhypertension
CausesCauses (4)(4)
ValvularValvular or or structuralstructural abnormalityabnormality
MitralMitral stenosisstenosisEndocarditis Endocarditis Mitral aortic regurgitation Mitral aortic regurgitation Obstruction due Obstruction due toto atrialatrial myxomamyxoma or or thrombusthrombusPapillaryPapillary musclemuscle dysfunctiondysfunction or or ruptureruptureRupturedRuptured septumseptum or or freefree wallwallArrhythmiasArrhythmias
MainMain CauseCause
MiocardialMiocardial InfarctionInfarction (MI)(MI)Cardiogenic Shock Complicates 4.2Cardiogenic Shock Complicates 4.2--7.2 % of the MIs7.2 % of the MIs
Leading cause of death (Leading cause of death (mortalitymortality rate rate ≈≈ 50%)50%)
Usually develops for losses of tissue mass Usually develops for losses of tissue mass greatergreater thanthan 40 %40 %
(N Engl J Med 1999;340:1162-8.)
Ann Intern Med. 1999;131:47-59.
Loss of myocardial contractility
↑ HR↑ Inotropism ↑ Arterial tone ↑ Venous tone
↓ CO ↓ Blood pressure
↑ Adrenergic response
↑ Myocardial VO2 ↑ Afterload
Worsening in myocardial ischemia
↑ Preload
↑ Ventricular ∅↓ Myocardial perfusion
Normal
Depressedcontractility
PreloadPreload doesdoes notnot help…help…10
8
Card
iac
Out
put
(l/m
in)
6
4
2
5 110 5 20 25 30 35Wedge Pressure (mmHg)
In the In the lungslungs
↓ Splancnic perfusion
H2O retention
↑ Preload ↓ Diastolic Function
↑ Atrial pressure
Pulmonary vasculature congestion
Worsening of hypoxaemia
Challenging the paradigm
• LV EF approx 30%• Average SVR not elevated ( wide range)• SIRS obviuos• Survivors class I CHF status
From the SHOCK study
Influence of inflammatory response
FromFrom: : CirculationCirculation 2003; 107: 29982003; 107: 2998--30023002
RoleRole of of systemicsystemic inflammationinflammation
•• A A substantialsubstantial numbernumber of of patientspatients diedie withwitha a normalizednormalized CI in CI in absenceabsence of of obviousobviousinfectioninfection (22.5%)(22.5%)
•• ReleaseRelease of of mediatorsmediators secundarysecundary toto gutguthypoperfusionhypoperfusion? ?
ChestChest 2003, 124:18852003, 124:1885--18911891
LeftLeft ventricleventricle alwaysalways guiltyguilty??
SHOCK SHOCK RegistryRegistry::
•• In 49 of 993 In 49 of 993 patientspatients (5%) the shock (5%) the shock waswascausedcaused byby rightright heartheart infarctioninfarction
•• MortalityMortality notnot differentdifferent in the in the rightright vsvs leftleftventricularventricular shockshock
J J AmAm CollColl CardiolCardiol 2003, 341:12732003, 341:1273--7979
CausesCauses of RV of RV failurefailure
RightRight heartheart infarctioninfarction
Acute Cor Acute Cor PulmonalePulmonaleMassiveMassive PulmonaryPulmonary embolismembolismAcute Respiratory Distress Acute Respiratory Distress SyndromeSyndrome
The RV The RV failurefailureLoss of myocardial contractility
↓ CO ↓ PAP↑ RV Volume
↑ RV Pressure
Tricuspid insufficency↓ LV preload
Venous district and splanchniccongestion
Hypoxaemia
↓ WP !WP !
IntInt Care Care MedMed 2004, 30:1852004, 30:185--9696
HemodynamicHemodynamic patternspatterns duringduring shockshock
BPBP HRHR COCO CVPCVP WPWP
HypovolemicHypovolemic shockshock ↓↓ ↑↑ ↓↓ ↓↓
LeftLeft VentricularVentricular MIMI ↓↓ ↑↑ ↓↓ ↓↓ Or Or NlNl ↑↑
RightRight VentricularVentricular MIMI ↓↓ ↑↑ ↓↓ ↑↑ ↓↓ Or Or NlNl
ExtracardiacExtracardiac ObstructiveObstructivePericardialPericardial TamponadeTamponade ↓↓ ↑↑ ↓↓ ↑↑ EqualizedEqualized
MassiveMassive PumonaryPumonary EmbolismEmbolism ↓↓ ↑↑ ↓↓ ↑↑ Or Or NlNl ↓↓ Or Or NlNl
↓↓ Or Or NlNl
↓↓
CardiogenicCardiogenic shockshock
SepticSeptic//AnaphilacticAnaphilactic shockshock ↓↓ ↑↑ ↑↑ ↓↓ Or Or NlNl
CARDIOGENIC SHOCKTherapy
• Immediate resuscitation
• Early definition of coronary anatomy
• Early revascularization
CARDIOGENIC SHOCKImmediate resuscitation
• Pressure: dopamine noradrenaline dobutamine• Monitor ECG, defibrillators and drugs available
( 33% of SHOCK trial had CPR, VT, or VF)• Oxygen, CPAP, CPPV• Aspirin, heparin• Fibrinolitics if PCI > 90-120 min• IABP
CARDIOGENIC SHOCKEarly definition of coronary anatomy
Circulation 2003: 107: 2998
Circulation 2003: 107: 2998
CARDIOGENIC SHOCKEarly revascularization
Intraaortic Balloon Counterpulsation
BMJ 2003;326:1450-1452
Intraaortic Balloon Counterpulsation
BMJ 2003;326:1450-1452
Intraaortic Balloon Counterpulsation
BMJ 2003;326:1450-1452
Mortality rate after MI
Better drugs ?(N Engl J Med 1999;340:1162-8.)
Patients with cardiogenic shock complicating MI
Medical Therapy
- Thrombolitic therapy- Intraaortic balloon
counterpulsation
Revasculatization
- Angioplasty/Bypass surgery- Intraaortic balloon
counterpulsation
ConclusionsConclusionsAt 30 days there was no significant overall benefit of early revascularization for patients with myocardialinfarction who had cardiogenic shock due to leftventricular dysfunction. However, early revascularizationresulted in lower mortality from all causes at six months.
The The currentcurrent strategystrategy
Cardiogenic shock : commonest cause of death in AMI. -thrombolysis can be attempted with inotropic support or augmentation of bloodpressure with the intra-aortic balloon pump- greatest mortality benefit seen afterurgent coronary angiography and revascularisation
BMJ 2003;326:1450-1452
CARDIOGENIC SHOCK
• VAD• LVAD• ECMO• Et al……
Rossi F et al J.Thorac Cardiovasc Surg 100:914:1990
Healing the heart with ventricular assist devices therapy
• Reversal of left ventricular remodeling: reduction of LV size, improved contractility, regression of myocyte hypertrophy
• Molecular remodeling: apoptosis regulation, improved calcium exchange