Post on 11-Apr-2017
Revascularization Strategies in Management of Cardiogenic shock
Prof. Christian JM Vrints
ESC 2014 Revasc guidelines: management of patients with acute heart failure in the setting of ACS
S Windecker , P Kolh et al. Eur Heart J (2014) 35, 2541–2619
The SHOCK Trial has been the most important study for management guidelines in patients with cardiogenic shock
JS Hochman et al. N Engl J Med 1999;341:625-34
Early Revascularization and 1 Year Survival-SHOCK trial
4437 34
5450 47
30 days 6 months 1 year0
10
20
30
40
50
60
Survival %
Medical therapy
Revascularizationp=0.03p=0.11 p=0.03
• 13% absolute increase in 1 year survival in patients assigned to early revascularization
• number needed to treat of <8 patients to save 1 life
JS Hochman et al. JAMA. 2001;285:190-192
SHOCK trial: CABG vs. PCI
PCI (%) CABG (%) p-value--------------------------------------------------------------------------Diabetes 26.9 48.9 0.02
LMCA 13.0 41.3 0.001
3 vessel disease 60.3 80.4 0.03
coronary jeopardy score 7.1±3.2 9.9±2.3 0.0001
HD White et al. Circulation. 2005;112:1992-2001.
Decreasing in-hospital mortality with increasing rates of early PCI in patients with cardiogenic shock
STEMI registry Germany
U Zeymer et al. ESC Congress Barcelona 2009
Ten-Year Trends in the Incidence and Treatment ofCardiogenic Shock - AMIS Plus Registry
RV Jeger et al.Ann Intern Med. 2008;149:618-626
SHOCK trial: 81% of the patients with cardiogenic shock have multivessel disease
HD White et al. Circulation. 2005;112:1992-2001.
How to treat:–Culprit vessel PCI?–Multivessel PCI?
• Immediate?• Staged procedure?
–CABG?
What do the guidelines recommend?
• Approximately 50% of STEMI patients have significant multivessel disease. Only the infarct-related artery should be treated during the initial intervention. There is no current evidence to support emergency intervention in non-infarct-related lesions.
• The only exceptions, when multivessel PCI during acute STEMI is justified, are in patients with cardiogenic shock in the presence of multiple, truly critical (≥90% diameter) stenoses or highly unstable lesions (angiographic signs of possible thrombus or lesion disruption), and if there is persistent ischaemia after PCI of the supposed culprit lesion.
G. Steg, S James et al. European Heart Journal (2012) 33, 2569–2619
ESC STEMI Guidelines 2012
SHOCK trial: most patients were treated with single vessel PCI of the culprit lesion
HD White et al. Circulation. 2005;112:1992-2001.
Multivessel disease 81%
PCI of infarct related artery only 87%
Complete revascularization 23%
STEMI with shock: Multivessel PCI
Advantages
• Improves:• Peri-infarct blood flow• Remote ischemia in perfusion
territory non–IRA
Disadvantages
• Clinical storm scenario• Pro-thrombotic
• Pro-inflammatory
• PCI of non critical lesions• Distal embolization• No reflow• More:
• Stents
• Contrast
• Radiation
IschemiaLV
dysfunction
Hypotension
X
STEMI with MVD & cardiogenic shock: culprit or multivessel PCI?
In hospital outcomes shock pts.
1 vesselPCI
Multi-vessel PCI
pvalue
Patients 2654 433
Death 27.8% 36.5% <0.01
Death in lab
2.7% 5.8% 0.25
Stroke 1.5% 2.6% 0.18
Bleeding 12.5% 13.8% 0.44
Renal failure
7.1% 9.7% 0.03
Odds ratios mortalityNational Cardiovascular Data Registry
MA Cavender et al. Am J Cardiol 2009;104: 507-513
Multi- vs. 1-vessel PCI
Outcomes of Culprit Versus Multivessel PCI in Patients With MVD Presenting With STEMI Complicated by Shock
Matthew A. Cavender et al.J INVASIVE CARDIOL 2013;25(5):218-224
Patients undergoing MVPCI for STEMI-related shock are clinically different than those treated with culprit PCI only; however, after risk adjustment both groups have similar short- and long-term outcomes.
199 pts @ Cleveland Clinic 2002-2010
Outcomes of Multivessel PCI in Acute MI & Cardiogenic Shock (EHS-PCI Registry)
T Bauer, U Zeymer et al. Am J Cardiol 2012;109:941–946
determinants for hospital mortality
**
*
336 pts MV-PCI 24%
PPCI in STEMI with Resuscitated Cardiac Arrest, and Cardiogenic Shock
D Mylotte et al. J Am Coll Cardiol Intv 2013;6:115–25
Culprit-only vs. multivessel PCI in cardiogenic shock complicating STEMI
Mortality MACE
JH Yang et al. Crit Care Med 2014; 42:17–25
Culprit or multivessel revascularisation in STEMI with cardiogenic shock
46.8
0.6 0.2 1.6
9.5
35.8
1.2 0.13.2 4.3
MACE before discharge
Death
Non-fatal MI
Non-fatal Stroke
Bleeding
Dialysis
0
10
20
30
40
50
% Events
MV-PCI (n=173) Culprit-PCI (n=562)
German PCI registry (2008-2011)735 patients with STEMI, cardiogenic shock & MVDMultivessel PCI in 23,5%
U Zeymer et al. Eurointervention 2015 In press.
Culprit or multivessel revascularisation in STEMI with cardiogenic shock
Jin Sup Park et al.Heart doi:10.1136/heartjnl-2014-307220. In press.
Korean Acute Myocardial Infarction Registry (2006-2012)510 ptsMultivessel PCI in 24,3%
Conflicting results…
Trial N Mortality multivessel
PCI, %
Mortality culprit lesion only PCI, %
Adjusted odds ratio or hazard ratio
(95% CI)
Webb et al. 74 55 20 2.75 (1.05–7.25)Cavender et al. 3087 36.5 27.8 1.5 (1.22–1.95)Bauer et al. 336 48.8 37.4 1.28 (0.72–2.28)Mylotte et al. 266 20.4 43.9 0.57 (0.38–0.84)Yang et al. 338 35.0 30.6 1.06 (0.61–1.86)Zeymer et al. 735 46.8 35.8 1.5 (1.15–1.84)Park et al. 510 12.9 17.9 0.69 (0.40-1.19)
A RCT is underway!
Treatment Algorithm for Cardiogenic ShockAcute MI & Cardiogenic Shock
Fluids for optimal preload
Vasopressors - Inotropes
Early Revascularization
1 – 2 vessel disease
Moderate 3 vessel disease
Left main disease
Severe 3 vessel disease
PCI infarct related artery CABG
Acute multivessel PCI
Staged multivessel PCI
Staged CABG
MCS
HTX
Weaning+-
Peripheral Perfusion
LV-Dysfunctionsystolic diastolic
Death
Hypoxia
LVEDP Lung edema
Cardiac Output Stroke volume
VasoconstrictionFluid retention
Hypotension
Coronary- perfusion
Acute Myocardial Infarction
Reperfusion:PCI/CABG
Ischemia
Mechanical Support:IABP/LVAD
Inotropes/Vasopressors
Cardiogenic Shock Spiral
Thiele et al. Eur Heart J 2010;31:1828-1835
Progressive LV-Dysfunction
Peripheral Perfusion
LV-Dysfunctionsystolic diastolic
Death
Hypoxia
LVEDP Lung edema
Cardiac Output Stroke volume
VasoconstrictionFluid retention
Hypotension
Coronary- perfusion
SIRS
eNOSiNOS
NO Peroxynitrite
IL-6 TNF-α
SVR Pro-InflammationCatecholamine sensitivity Contractility
Acute Myocardial Infarction
Reperfusion:PCI/CABG
Ischemia
++Mechanical Support:IABP/LVAD
Inotropes/Vasopressors
+
+
Bleeding/Transfusion
Cardiogenic Shock Spiral
Thiele et al. Eur Heart J 2010;31:1828-1835
SIRS: Systemic Inflammatory Response Syndrome
Progressive LV-Dysfunction
• An integrate approach is needed with:– Early revascularization– Inotropic support– Mechanical support eventually as bridge to HTX
• Multidisciplinary collaboration needed by:– Interventional cardiologists– Cardiac surgeons– Intensive acute cardiac care cardiologists– Heart failure cardiologists
Cardiogenic shock remains a major challenge in acute cardiac care