ST-Elevation Myocardial Infarction& Cardiogenic Shock

- What Should We Do?

Advanced Angioplasty 2008

Dan Blackman

Leeds General Infirmary

Conflicts of interest

• Advisory Boards– Cordis– Boston Scientific– Medtronic– Nycomed– Lilly– St Jude

• Travel/Sponsorship– Cordis– Boston Scientific– Medtronic– Abbott– St Jude

Causes of Cardiogenic Shock

Predominant LV Failure

74.5%

Acute Severe MR

8.3%

VSD

4.6%

Isolated RV Shock

3.4%

Tamponade/rupture

1.7%Other

7.5%

Shock Registry

JACC 2000 35:1063

Survival from mechanical causes

94%

71%

47%

39%

28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

VSD Acute Severe MR

In-h

ospi

tal M

orta

lity

(%)

No SurgerySurgeryPercutaneous closure

Shock Registry JACC 2000;36:1104 & 36: 1110

GUSTO 1 Circulation 2000;101:27

Holzer R CCI 2004;61:196

Emergency revascularisation - SHOCK Trial

47%50%

53%56%

63%66%

0%

10%

20%

30%

40%

50%

60%

70%

30 days (n=302) 6 months (n=301) 12 months (n=299)

Mort

ality

(%

)

ERVIMS

85% of survivors NYHA Class I/II at 12 months

Hochman JAMA 2000;285:190

p=0.11

p=0.03

Emergency revascularisation in the Elderly- SHOCK Trial

41%

75%

57%53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

<75 years (n=246) >75 years (n=56)

30-d

ay M

ort

ality

(%

)ERVIMS

• >75 years ERV vs IMS baseline characteristics– LVEF 28% vs 36% p=0.051– Anterior MI 63% vs 41% p=0.18– Female 54% vs 31% p=0.11

p=0.01

p=0.01

Elderly - SHOCK & other registry data

48% 47% 46%

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

SHOCK Registry Mayo Clinic Northern NewEngland

30-d

ay M

ort

ality

(%

)

ERVIMS

n=44 n=233 n=61n=74

Single vessel or Multivessel PCI?

- SHOCK Trial• 81% of PCI patients multivessel disease

• 85% PCI IRA only; 23% complete revascularisation

80%

46%45%

54%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1-y

ear

mort

alit

y (%

)

MV PCISV PCI

p<0.01

Shock Trial Shock Registry

p=NS

“The panel believes that all accessible vessels should be treated in patients with cardiogenic shock”

“Current Recommendations:-1-2 vessel disease: PCI IRA3VD: PCI IRA + staged complete revascularisation

Early MV PCI may be warranted if shock persists despite IRA PCI”

Is there a role for CABG – SHOCK Data

48%46%

53%

24%

0%

10%

20%

30%

40%

50%

60%

SHOCK Trial SHOCK Registry

1-y

ear

mort

ality

(%

)

PCICABG

p=NS

• SHOCK Trial CABG vs PCI baseline characteristics– LMS Disease 41% vs 13% p=0.051– 3VD 80% vs 60% p=0.18– Diabetes 49% vs 27% p=0.11

n=47n=81 n=276 n=109

Intra-aortic balloon pump counterpulsation

63

69

43

59

68

4749

34

45

23

0

10

20

30

40

50

60

70

80

Shock Registry(n=292)

NRMI Registry(n=23,180)

TACTICS GUSTO I & III Kovack (n=46)

Mor

talit

y (%

)

TT onlyTT + IABP

IABP in Cardiogenic Shock Primary PCI

67

49

42

46

0

10

20

30

40

50

60

70

80

Thrombolysis only Thrombolysis + IABP Primary PCI only Primary PCI + IABP

In-h

osp

ital M

ort

ality

(%

)Retrospective analysis of 23,180 patients from NRMI database

7268 treated by IABP

Timing of IABP in Cardiogenic Shock Primary PCI

15%13%

15%

35%

30%

35%

0%

5%

10%

15%

20%

25%

30%

35%

40%

CPR VF/ VT arrest Any event

Eve

nt

rate

(%

)

IABP pre (n=62)IABP post/ none (n=57)

• Single centre registry Primary PCI for shock

Brodie AJC 1999;84:18

Inotropes and Vasopressors

No meaningful data!

ACC/AHA Guidelines

SBP <70:-

Norepinephrine (0.5-30 g/min)

Switch to Dopamine (5-15 g/kg/min) once SBP ≥80

SBP 70-100

Dopamine (5-15 g/kg/min)

Add dobutamine (2-20 g/kg/min) once SBP ≥90

Percutaneous left ventricular assist devices

• Even with revascularisation and IABP support mortality from cardiogenic shock post STEMI remains ≥50%

• Recovery of myocardial performance following successful revascularisation may take several days. During this time many patients succumb to low cardiac output

• If effective, active cardiac support could be provided while awaiting the beneficial effects of revascularisation, survival rates may be enhanced

Tandem Heart pLVAD• Left atrial-to-femoral arterial LVAD• Low speed centrifugal continuous

flow pump• 21F venous transeptal cannula• 17F arterial cannula• Maximum flow 4L/minute• Cost: 7.5K

Tandem Heart Outcome Data

42%

47%45%

36%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Thiele (n=41) Burkhoff (n=33)

30 d

ay m

ort

alit

y (%

)Tandem HeartIABP

Improved haemodynamic parameters

Increase in bleeding, limb ischaemia, and sepsis

Thiele EHJ 2005;26:1276. Burkhoff AHJ 2006;152:e1

p=NS

Impella• Axial flow pump• Much simpler to use• Increases cardiac output & unloads LV• LP 2.5

– 12 F percutaneous approach; Maximum 2.5 L flow

• LP 5.0– 21 F surgical cutdown; Maximum 5L flow

• Cost: 3-5K

Pressure Lumen

Motor

Blood outlet

Blood Inlet

Impella outcome data

• 1 RCT of Impella 2.5 in AMI Cardiogenic Shock

• ISAR-SHOCK

– 26 patient RCT Impella vs IABP Cardiac Index, MAP (by 10mmHg) vs IABP– Complications ≤ IABP

– No difference in mortality

What we should do about STEMI Cardiogenic Shock

• Emergency angiography and revascularisation: Primary PCI preferably– All patients <75 years

– Selected patients ≥75 years

• On-table echo to rule out mechanical defects

• Stabilise the patient in the lab before revascularisation– IABP

– Pressors if required (Norepinephrine/dopamine)

– Anaesthetic support

• Consider calling the surgeon for true surgical disease

• PCI culprit artery. Other vessels if shock persists

• Use abciximab for PCI

• Consider percutaneous LVAD if shock persists with IABP + multi-vessel

revascularisation