Primary Angioplasty and Hemodynamic Support in Cardiogenic Shock Department of Internal Medicine,...
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Transcript of Primary Angioplasty and Hemodynamic Support in Cardiogenic Shock Department of Internal Medicine,...
Primary Angioplasty and Hemodynamic Support in
Cardiogenic Shock
Department of Internal Medicine, College of Medicine, Yonsei University
Hyuck Moon Kwon, M.D.
Epidemiology of Cardiogenic Shock
Occurrence of shock
STEMI Non- STEMI
4.2-7.2%(GUSTO)
2.9%(PURSUIT)
Median time from enrollment to shock
9.6h 76h
Unstableangina
2.1%(PURSUIT)
94h
Hasdai et al. JACC 2000;36:687
Definition of Cardiogenic Shock
SBP < 90mmHg for >30min-1 hr that is :• Unresponsive to fluid administration alone• Secondary to cardiac dysfunction, or• signs of end-organ hypoperfusion, or • CI<2.2L/min/m and PCWP>15-18mmHg.
• SBP increase to>90mmHg within 1 hr after administration of inotrophic agents
• Death within 1 hr of hypotension but met other criteria for cardiogenic shock.
ACC clinical data standard JACC 2001;38:2127
ACC/AHA Guidelines (1999/2000) for PCIin Cardiogenic Shock
• Class I recommendation• Primary PTCA: within 36 hrs of an acute ST
elevation / Q-wave or new LBBB who develop cardiogenic shock are < 75 years old,
• Revascularization (PCI or CABG) within 18 hrs of onset of shock.
J Am Coll Cardiol 1999;34:`904
Predictors of Cardiogenic Shockafter STEMI
• Patient’s age - most important• SBP• HR• Killip Class
- Hasdai et al,Lancet 2000;356:749
Primary Angioplasty in CS
Employed criteria ? GUSTO-1 Selection bias ? SHOCK vs SMASH Randomized controlled study? Time of studies ?
Overall mortality: 44% Successful PCI: 33% Unsuccessful PCI: 81%
• Cardiogenic shock : 7.2% (among 41,021 pts)
• Overall 30-day mortality : 55%
• 30-day mortality of CABG group : 29%
• 30-day mortality of PTCA group : 22%
• Comparison of 1 yr mortality, PTCA vs no PTCA :
the hazard ratio : 0.81(95% CI,0.71-0.94; p<0.005)
•Limitations : not randomized study. Selection bias.
GUSTO-I (Cardiogenic shock subgroup analysis)
SHOCK trial : Randomized and controlled study
Acute Myocardial Infarction
Shock
Randomization
Emergency Revascularization Initial medical Stabilization
IABP/Pharmacological supportPossible prior thrombolysisEmergency earlyPTCA(60%)/CABG(40%)<= 6 hrs
IABP/Pharmacological supportThrombolysis unless absoluteContraindication (63%)Delayed revasc.(25%) >54hr
<= 36hr
<= 12hr
Hochman et al,NEJM 1999;341:625
• Primary end point : 30-day mortality• Secondary end point : 6 mo. mortality
Outcome and Subgroup
30-day mortalityTotalAge<75yrAge>=75yr6-mo. mortalityTotalAge<75yrAge>=75yr
ERV
46.7(152) 41.4(128) 75.0(24)
50.3(151) 44.9(127) 79.2(24)
Medical Therapy
56.0(150)56.8(118)53.1(32)
63.1(149)65.0(117)56.3(32)
Difference
-9.3 -15.4 +21.9
-12.8 -20.1 +22.9
percent(number in subgroup)
Relative risk
0.83 0.73 1.41
0.80 0.70 1.41
P-value
0.110.01
0.0270.003
SHOCK Trial : Mortality among Study Patients
Hochman et al ,NEJM 1999;341:625
PCI in the SHOCK Trial Registry (93-97’, n=884)
Webb J et al, Am. Heart J.2001;141:964-71
In-hospital mortality: 46.4% in PCI (n=276) vs 78.0% in medically (n=499) MI-PCI: Median 8.8hrs, Shock-PCI: 3.3hrs
PCI within 6 hrs of MI 40.2%PCI within 6-12 hrs of MI 50.9%PCI within 12-24 hrs of MI 60.5%PCI within 24hrs of MI 43.9%
Pts with PCI: younger, shock earlier, higher LVEF & CI
Final TIMI flow grade after PCI and in-hospital mortality rates in SHOCK Registry patients with pump(Lt.or Rt.ventricular) failure. (P< 0.001).
( Webb J et al, Am. Heart J.2001;141:964-71)
0
20
40
60
80
100
0 or 1(n=35) 3(n=111)
85.7%
50.0%
In-h
ospi
tal m
orta
lity
(%)
33.3%
2(n=24)Final TIMI Flow Grade
Angiographic success and in-hospital mortality rates in SHOCK Registry patients with pump failure. Success is defined as residual stenosis<50% and final TIMI flow grade of 2 or 3(P< 0.001).
( Webb J et al, Am. Heart J.2001;141:964-71)
0
20
40
60
80
100
Unsuccessful(n=40) Successful(n=119)
82.5%
36.1%
In-h
ospi
tal m
orta
lity
(%)
Region
ANCEuropeABUSAP value
Hospital mortality(%)
58 65 79 39 < 0.0001
ERV(%)
25 31 46 57 <0.0001
Stent use
25 80 53 80 0.0019
GPIIbIIIa Inhibitor 5 15 9 26 0.0005
Global Use of Revascularization for Pts. in Cardiogenic Shock: Global registry of Acute Coronary Events (GRACE, 99-00’, n=535)
ANC: Australia/New Zealand/Canada, AB: Argentina/brazil
Dauerman et al, Am J cardiol 2001;88(suppl 5A)
•The most powerful predictor of in–hospital survival : PCI with stenting(n=535, odds ratio, 5.8 ; 95% confidence interval, 3.3-10.4)
Long-term Results after acute PCI in AMI with shock
12-months survival rate 47% SHOCK trial
60% Ajani et al. AJC 2001;87:633
80% Ammann et al. Int J of cardiology 2002;82:127
Early prediction - ERV with stenting & anti-PLT !!
Beneficial effect of GP IIb/IIIa receptor blockers in patients undergoing primary PCI/Stenting in CS:
1-month mortality (n=74) 19 vs 41%Antoniucci D et al. Am J Cardiol. 2001;88:5A
In hospital mortality (n=323) 26.4 vs 34.4%Moscucci M et al. JACC. 2002;39:330A
Glycoprotein IIb/IIIa inhibitors
Hemodynamic Support in Cardiogenic Shock
IABP in Cardiogenic Shock
• Diastolic inflation - Augmentation of DBP
• Systolic Deflation - Afterload Reduction
• Contraindicated in severe Aortic regurgitation !
-Increases diastolic coronary arterial perfusion
- Reduce LV wall stress- Decrease myocardial oxygen demand- Increase in cardiac output
• IABP as an an adjunctive treatment to revascularization in GUSTO-I trial, a trend towards lower 30-day and 1 -year mortality rates. (Anderson et al. JACC 1997;30:708-715)
(Barron et al,Am heart J 2001;141:933-939)
IABP in Cardiogenic Shock complicating AMI
• SHOCK trial : IABP used in 86%• National Registry of MI-2 IABP in 7268/23180 (31%): Thrombolytic therapy with IABP :49 vs 67 % Primary angioplasty with IABP :47 vs 45 %
Conclusion
• Prevention is the best policy: identification of pre-shock state followed by preventing deterioration into cardiogenic shock.
• Strategy of ERV: PTCA/CABG accompanied with IABP support. for > 75yrs old,invasive strategy on case by case basis.
• TIMI flow after PCI was strongly associated with in-hospital mortality rate.
Thrombolytic therapy
• The outcome of cardiogenic shock is closely linked to the patency of the culprit coronary arteries
• Thrombolytic therapy has decreased the occurrence of shock among patients with persistent STEMI.
• The GUSTO-I : t-PA is more efficacious than streptokinase in preventing shock.
Thrombolysis in cardiogenic shock
• Results have been disappointing• Cause : ? limited efficacy of lytics in the
setting of low perfusion pressure.• GISSI-I Study
Mortality of thrombolysis(streptokinase) group = 69.9% Mortality of. control group = 70.1%
-David Hasdai et al,Lancet 2000;356:753