REPERFUSION IN CARDIOGENIC SHOCK By Dr. Hamdy Abdalla Badawy

1. Reperfusion Therapy in
Cardiogenic Shock after MI
By
Dr.Hamdy abdalla Badawy

2. Cardiogenic Shock
• One of the most common causes of death after an MI.
• Mostly occurs < 48 hrs after hospitalization, rather at presentation
(90% vs 4.5%).
• About 6% of STEMI, 3% of NSTE ACS patients.
• 60-80 % mortality (pre thrombolytic),
• Survival at 3yrs and 6 yrs – 40% and 30% respectively.
• Early recognition, prompt revascularization helps in improved survival

3. Definition
• Marked and persistent (>30 min) hypotension
• SBP < 90 mmHg, or
• Drop in SBP by 30 mm Hg below basal levels, or
• Supportive pharmacotherapy required to maintain SBP > 90 mm Hg.
• Reduced cardiac index (<2.2 liters/min/m2)
• signs of impaired organ perfusion (altered mental status,cold
extremeties,oliguria)

4. CAD patients at risk…
• Extensive Anterior wall STEMI
• LMCA stenosis + previous LVDysfunction.
• Osteoproximal LAD total occlusion.
• LAD + Previous h/o CAD.
• TVD + Diabetes.

5. SHOCK trial
• Patients were randomly assigned to emergency revascularization (PCI or
emergent CABG) or initial medical stabilization, including fibrinolysis.
• Overall mortality at 30 days did not differ significantly between the
revascularization and medical therapy groups. Six-month mortality was
lower in the revascularization group than in the medical therapy group
• lower mortality from all causes at 6 months. (50.3 % vs. 63.1 %, P=0.027).
• Early revascularization be strongly considered for patients with Acute
Myocardial Infarction complicated by cardiogenic shock

6. Why thrombolysis not effective?
Fibrinolysis is not effective in these patients owing to :
• Limited evidence.
• Complex mechanical, hemodynamic ,metabolic factors.
• Acidosis - impaired transformation of plasminogen to plasmin - decreased
efficacy
• ↓ coronary perfusion pressure – delivery of plasminogen activators to
thrombus impaired.

7. Pressure dependent thrombolysis
• Successful thrombolysis with tPA in patients with cardiogenic
shock after infusion of dopamine or NE (MAP>100mmHg).
• Combine therapy more beneficial than either therapy alone .
• Imp. Role in hospitals without revascularization facilities by
stabilizing patients and facilitating their transfer to teritiary
centers.

8. IABP assisted Thrombolysis
• Patients in cardiogenic shock
– TT had lower in-hospital mortality rates (54% vs 64%),
– IABP counterpulsation had lower in-hospital mortality rates
(50% vs 72%).
• Revascularization influenced in-hospital mortality rates
significantly (39% vs 78%).

9. recommendations for the use of reperfusion
• recommendations in patients with CS are similar to those for
most patients with MI and differ principally in the level of
evidence.
• For patients with ST elevation MI, we recommend revascularization as
opposed to fibrinolytic therapy (Grade 1A). This recommendation requires that
diagnostic coronary angiography be performed within 90 minutes of initial
hospital presentation.
• For those patients who cannot undergo timely PCI , we recommend fibrinolytic
therapy rather than no immediate reperfusion (Grade 1B).
• For patients with one or two vessel disease who do not have mechanical
complications, we recommend (PCI) of the infarct related artery as opposed to
CABG (Grade 1B).

10. • For patients with three vessel disease or left main disease who do not have
mechanical complications (such as acute mitral regurgitation or rupture of
the ventricular septal or free walls), we suggest immediate PCI as opposed
to CABG (Grade 2C)
• For patients with mechanical complications, we recommended immediate
CABG and attempt at repair of the mechanical defect as opposed to PCI
(Grade 1B).
• For patients with non-ST elevation MI, we recommend that
revascularization be performed as soon as possible as opposed to either
fibrinolytic therapy or no reperfusion (Grade 1B).

11. THANK YOU FOR YOUR
ATTENTION !