Primary Angioplasty and Hemodynamic Support in Cardiogenic Shock

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Primary Angioplasty and Hemodynamic Support in
Cardiogenic Shock

• Department of Internal Medicine, College of
  Medicine, Yonsei University
• Hyuck Moon Kwon, M.D.

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Epidemiology of Cardiogenic Shock
Unstable angina
STEMI
Non- STEMI
Occurrence of shock
4.2-7.2 (GUSTO)
2.9 (PURSUIT)
2.1 (PURSUIT)
Median time from enrollment to shock
9.6h
76h
94h
Hasdai et al. JACC 200036687
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Definition of Cardiogenic Shock

• SBP lt 90mmHg for gt30min-1 hr that is
• Unresponsive to fluid administration alone
• Secondary to cardiac dysfunction, or
• signs of end-organ hypoperfusion, or
• CIlt2.2L/min/m and PCWPgt15-18mmHg.
• SBP increase togt90mmHg 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 2001382127

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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 lt 75 years old,
• Revascularization (PCI or CABG) within 18 hrs of
  onset of shock.

J Am Coll Cardiol 199934904
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Predictors of Cardiogenic Shockafter STEMI

• Patients age - most important
• SBP
• HR
• Killip Class

- Hasdai et al,Lancet 2000356749
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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

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GUSTO-I (Cardiogenic shock subgroup analysis)

• 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
  plt0.005)
• Limitations not randomized study. Selection
  bias.

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SHOCK trial Randomized and controlled study
Acute Myocardial Infarction
lt 36hr
Shock
lt 12hr
Randomization
Emergency Revascularization
Initial medical Stabilization
IABP/Pharmacological support Possible prior
thrombolysis Emergency early PTCA(60)/CABG(40)lt
6 hrs
IABP/Pharmacological support Thrombolysis unless
absolute Contraindication (63) Delayed
revasc.(25) gt54hr

• Primary end point 30-day mortality
• Secondary end point 6 mo. mortality

Hochman et al,NEJM 1999341625
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SHOCK Trial Mortality among Study Patients
Outcome and Subgroup 30-day mortality Total Age
lt75yr Agegt75yr 6-mo. mortality Total Agelt75yr Ag
egt75yr
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
Relative risk 0.83 0.73
1.41 0.80 0.70 1.41
P-value 0.11 0.01 0.027 0.003

percent(number in subgroup)
Hochman et al ,NEJM 1999341625
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PCI in the SHOCK Trial Registry (93-97,
n884)
In-hospital mortality 46.4 in PCI (n276) vs
78.0 in medically (n499)
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
Webb J et al, Am. Heart J.2001141964-71
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Final TIMI flow grade after PCI and in-hospital
mortality rates in SHOCK Registry patients with
pump(Lt.or Rt.ventricular) failure. (Plt 0.001).
100
In-hospital mortality()
85.7
80
60
50.0
40
33.3
20
0
0 or 1(n35)
3(n111)
2(n24)
Final TIMI Flow Grade
( Webb J et al, Am. Heart
J.2001141964-71)
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Angiographic success and in-hospital mortality
rates in SHOCK Registry patients
with pump failure. Success is defined as residual
stenosislt50 and final TIMI flow grade of 2 or
3(Plt 0.001).
100
In-hospital mortality()
82.5
80
60
36.1
40
20
0
Successful(n119)
Unsuccessful(n40)
( Webb J et al, Am. Heart J.2001141964-71)
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Global Use of Revascularization for Pts. in
Cardiogenic Shock Global registry of Acute
Coronary Events (GRACE, 99-00, n535)
Hospital mortality() 58 65 79
39 lt 0.0001
Region ANC Europe AB USA P value
ERV() 25 31 46
57 lt0.0001
Stent use 25 80 53 80 0.0019
GPIIbIIIa Inhibitor 5
15 9 26
0.0005
ANC Australia/New Zealand/Canada, AB
Argentina/brazil

• The most powerful predictor of inhospital
  survival PCI with stenting
• (n535, odds ratio, 5.8 95 confidence
  interval, 3.3-10.4)

Dauerman et al, Am J cardiol 200188(suppl 5A)
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Long-term Results after acute PCI in AMI with
shock

• 12-months survival rate
• 47
  SHOCK trial
• 60
  Ajani et al. AJC 200187633
• 80 Ammann et al. Int J
  of cardiology 200282127
• Early prediction - ERV with stenting
  anti-PLT !!

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Glycoprotein IIb/IIIa inhibitors
Beneficial effect of GP IIb/IIIa receptor
blockers in patients undergoing primary
PCI/Stenting in CS 1-month mortality (n74) 19
vs 41 Antoniucci D et al. Am J Cardiol.
2001885A In hospital mortality (n323) 26.4 vs
34.4 Moscucci M et al. JACC. 200239330A
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Hemodynamic Support in
Cardiogenic Shock
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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

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IABP in Cardiogenic Shock complicating AMI

• 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 199730708-715)

• 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

(Barron et al,Am heart J 2001141933-939)
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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 gt 75yrs old,invasive strategy on
  case by case basis.
  
• TIMI flow after PCI was strongly associated with
  in-hospital mortality rate.

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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.

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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 2000356753