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Cardiac Pulmonary Edema and CardiogenicShock

胡為雄Frank-Starling Law

emuloV ekortSEnd-Diastolic Pressure“In the normal heart, the diastolic volume (preload) is the principal force that governs the strength of ventricular contraction.”

Otto Frank and Ernest Starling

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ACC/AHA Guidelines

Pulmonary Edema Flow

P : hydrostatic pressuresπ: oncoticpressuresKf: permeability constant of vessel wallδ: reflection coefficient3Pulmonary Edema

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ACC/AHA Guidelines

HEMODYNAMIC CHANGESPROGRESSIVE LEFT HEART FAILUREHours5CardiogenicShock

•Cardiogenicshock (CS) is a state of inadequate tissue perfusiondue to cardiac dysfunction, and complicates 7-10%of cases of acute myocardial infarction•Without treatment, cardiogenicshock is associated with a 70-80% mortality rate, and is the leading cause of death in patients hospitalized for an acute myocardial infarction63

ACC/AHA Guidelines

Classic Criteria for Diagnosis of Cardiogenic Shock

1.Systemic Hypotensionsystolic arterial pressure < 80 mmHg2.Persistent Hypotensionat least 30 minutes3.Reduced Systolic Cardiac FunctionCardiac index < 1.8 x m²/min4.Tissue HypoperfusionOliguria, cold extremities, confusion5.Increased Left Ventricular FillingPulmonary capillary wedge pressure > 18 mmHg7Frequency of CS Has Remained Steady Over Time

Frequency of CardiogenicShock : 7-9%

NRMI STEMI RegistryN=25,311Babaevet al JAMA 2005 294:44884

ACC/AHA Guidelines

Pathophysiologyof CardiogenicShock

9Causes of CardiogenicShock

SHOCKTrial and Registry (N=1160)

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11Ventricular SeptalRupture

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ACC/AHA Guidelines

Ventricular SeptalRupture

•Incidence 1-2%•

Echo•Timing 2-5 d p MI•IABP

•PE murmur 90%•InotropicSupport•Thrill common•

Surgical Timing is •Echo shuntcontroversial, but •PA cathO2 step up > 9%usually < 48 h

13147

ACC/AHA Guidelines

Free Wall Rupture

15Free Wall Rupture

•Incidence: 1-6%•Occurs during first week after MI•Classic Patient: Elderly, Female, Hypertensive•Early thrombolysis reduces incidence but Late increases risk•Echo: pericardial effusion, PA cath: equal diastolic pressure•Treat with pericardiocentesisand early surgical repair168

ACC/AHA Guidelines

Acute Mitral Regurgitation

17Management of Acute MR

•Incidence: 1-2%•Echo for Differential Diagnosis:–Free-wall rupture–VSD–Infarct Extension•PA Catheter: large v wave•Afterload Reduction•IABP•InotropicTherapy•Early Surgical Intervention1

ACC/AHA Guidelines

19Right Ventricular Infarction: Diagnosis

Clinical findings:

Shock with clear lungs,Elevated JVPKussmaul signECG:

ST elevation in R sided leadsEcho:

Depressed RV functionV4R Modified from Wellens. N EnglJ Med 1999;340:381.2010

ACC/AHA Guidelines

Management of RV Infarction

•Cardiogenic Shock secondary to RV Infarct has better prognosis than LV Pump Failure•IV Fluid Administration•IABP•Dobutamine•Maintain A-V Synchrony•Mortality with Successful Reperfusion = 2% vs. Unsuccessful = 58%21The Shock Trial has been the most important study

for management guidelines in patients with

cardiogenicshock

Hochmanet al NEJM 1999;341:6252211

ACC/AHA Guidelines

The SHOCK Trial (N=302)

Randomization from Apr 1993-Nov 1998

Primary Endpoint: Overall 30 day mortality

SecondayEndpoints: 6 month and 1 year mortality

23SHOCK TrialPrimary and Secondary Endpoints80P= .027P=.11)6063.1%%Immediate(56.0%y Revascularizationti4050.3%46.7%StrategyalMedical Stabilizationrtoas an Initial StrategyM20030 Days6 monthsPrimary EndpointSecondary EndpointHochmanet al, NEJM 1999; 341:625.2412

ACC/AHA Guidelines

PCI v. CABG in the Shock Trial

25SHOCK Trial: Age < 75Immediate Revascularization StrategyMedical Stabilization as an Initial Strategy80P < .0180P < 0.002606065.0%56.8%%4041.4%4044.9%20200030 Day Mortality6 Month MortalityHochmanet al, NEJM 1999; 341:625.2613

ACC/AHA Guidelines

SHOCK Trial: Age > 75Immediate Revascularization StrategyMedical Stabilization as an Initial StrategyP < .01P < 0.003808075.0%79.2%6060%53.1%56.3%404020200030 Day Mortality6 Month MortalityHochmanet al, NEJM 1999; 341:625.27NRMI Revascularization Rates Over Time By Age

•Mortality rates also decreased for those pts undergoing PCI•Use of PCI increased from 27.4% to 54.4% (p < 0.001)•Use of PCI was the strongest independent predictor of a lower in-hospital mortality (AOR 0.46; p < 0.001)Babaevet al JAMA 2005 294:4482814

ACC/AHA Guidelines

6 Yr Outcome of SHOCK All Patients

Hochmanet al JAMA 2006; 295:2511 29CardiogenicShockNRMI STEMI Registry (N=25,311)Mortality Rates Over Time•Age, 69.4 years60.3%47.9%70•Women, 42.6%60P < 0.001•Hypertension, 49.7%50•Diabetes, 27.2%4030•Prior MI, 23.2%20•Prior CHF, 15.2%100•Prior PCI, 9.1%1995 2004•Prior CABG, 12.2%Babaevet al JAMA 2005 294:4483015

ACC/AHA Guidelines

Prognosis Is Worse With NSTEMI

likely related to the extent of underlying disease

31Multivariable Mortality Predictors

•Increasing age 1,2,3,4,7and female gender7•Lower left ventricular ejection fraction 4,6•Chronic renal insufficiency7•Initial6and Final TIMI Flow grade 14•Lower systolic blood pressure 1•Diabetes mellitus 5•Prior MI 2•Increasing time from symptom onset to PCI 1,4•Total Occlusion of the LAD 7Mitral regurgitation•MultivesselPCI (p = 0.040)1,4,61Webb et al JACC 2003;42:13804 Zeymeret al EHJ 2004;25:3227 Klein et al AJC 2005; 96:352Sutton Heart 2005;91:3395Tedesco JV Mayo ClinProc 2003; 78:5613 Tedesco AHJ 2003:146; 4726 Sanborn JACC 2003:42; 13733216

ACC/AHA Guidelines

ACC/AHA Guidelines for Cardiogenic ShockClass I1.Early revascularization, either PCI or CABG, is recommended for patients < 75 years oldwith ST elevation or new LBBB who develop shock unless further support is futile due to patient’s wishes or unsuitability for further invasive care.2.Fibrinolytic therapy should be administered to STEMI patients with cardiogenicshock who are unsuitable for further invasive care and do not have contraindications for fibrinolysis.3.Echocardiography should be used to evaluate mechanical complications unless assessed by invasively33ACC/AHA Guidelines for Cardiogenic ShockClass IIa1.Pulmonary artery catheter monitoring can be useful for the management of STEMI patients with cardiogenicshock.2.Early revascularization, either PCI or CABG, is reasonable for selected patients > 75 yearswith ST elevation or new LBBB who develop shock < 36 hours of MIand who are suitable for revascularization that is performed < 18 hours of shock. Patients with good prior functional status who agree to invasivecare may be selected for such an invasive strategy.3417

ACC/AHA Guidelines

35CARDIOGENIC SHOCK

MECHANICAL SUPPORT

•IABP Counterpulsation•ECMO•Ventricular assist devices3618

ACC/AHA Guidelines

IABP

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ACC/AHA Guidelines

39IABP support was associated with a ↓in mortality:

* NRMI-2 with lysis, from 67% to 49%* SHOCK Trial, from 63% to 47%4020

ACC/AHA Guidelines

Contraindications to IABP

•Significant aortic regurgitation•Abdominal aortic aneurysm•Aortic dissection•Uncontrolled septicemia•Uncontrolled bleeding diathesis•Severe bilateral peripheral vascular disease uncorrectable by peripheral angioplasty or cross-femoral surgery•Bilateral femoral-poplitealbypass grafts for severe peripheral vascular diseaseGrossman’s 2000

41ACC/AHA Guidelines for Cardiogenic Shock

Class I1.IABP is recommended for STEMI patients when cardiogenicshock is not quickly reversed with pharmacological therapy. The IABP is a stabilizing measurefor angiography and prompt revascularization.2.Intra-arterial monitoring is recommended for the management of STEMI patients with cardiogenicshock.4221

ACC/AHA Guidelines

ECMO

extracorporeal membrane oxygenation

extracorporeal life support

43ECMO

•Short-term cardiopulmonary support•Buy time to decide the next step–Recovery–Transplantation–Long-term device (ventricular assist device)–Operation (CABG, pulmonary embolectomy,..)–Give-up4422

ACC/AHA Guidelines

Ventricular Assist Devices

45Ventricular Assist Devices

•RVAD, LVAD, BiVAD•Nonpulsatile pump•Placed in parallel with RV, LV or both ventricles•Adjusted to provide total systemic flow of 2-3 L/min/M2•Complications in 50% of patients:–bleeding–systemic embolism4623

ACC/AHA Guidelines

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