Shock, Anterior MI and Acute Cardiovascular Care

1. How To Recognise And Manage A
Pre-shock Setting In The Context Of
Anterior STEMI?
Dr Han Naung Tun, MBBS, MD, FACTM
National Representative Heart Failure Specialist of Tomorrow for Myanmar in HFA and
Ambassador of Echocardiography in EACVI, ESC
Council of Clinical Practice and Working Groups of European Society of Cardiology ,
France

2. Preamble
Main Topic: Acute Cardiac Care – Cardiogenic Shock

3. Learning outcomes
Persistent hemodynamic compromise without criteria for shock is relatively
common after anterior STEMI treatment;
Routine mechanical support is not supported by evidence in cardiogenic
shock but an upfront strategy might be useful in this peculiar setting which
is prone to rapid deterioration;
Clinical features and invasive hemodynamic parameters may guide decision-
making.

4. Patient Presentation
65 y.o. male with multiple risk factors
p.c.: typical chest pain and worsening dyspnea (Killip 3)
BP: 105/55 mmHg
Lactates: neg
ECG: anterior STEMI

6. Cath-lab
The patient is immediately transferred to
the cath-lab and angio is performed:
LAD: 100% occlusion (culprit)
RCA: >90% occlusion
LCx: >90% occlusion

7. Which is the appropriate next step according to ESC guidelines?
A. PCI of the infarct-related artery
B. PCI of all diseased vessel
C. Systemic thrombolysis

8. PCI of the LAD is
performed with good
result (TIMI flow 3) … but
no symptomatic
improvement is observed.
The patient is still dyspneic
(Killip 3); BP is 100/55
mmHg; Lactates are
borderline-negative;
Residual myocardium at
risk is large

9. Can we make the diagnosis of cardiogenic shock?

10. What are the diagnostic criteria for cardiogenic shock?
A. Systolic BP < 90 mmHg despite support, irrespective of signs and
symptoms
B. Symptoms and sign of organ hypoperfusion, irrespective of systolic BP
C. Both refractory hypotension (systolic BP < 90 mmHg) and
signs/symptoms of organ hypoperfusion must be present

11. • Systolic blood pressure <90 mmHg or vasopressors required
• Pulmonary congestion or elevated LV filling pressures (e.g. PCWP >18
mmHg)
• Signs of impaired organ perfusion
• Impaired organ perfusion:
• Cold, clammy skin and extremities
• Oliguria with urine output <30 mL/hour
• Serum lactate >2.0 mmol/L
Thiele et al., IACC Textbook, 2019
Cardiogenic Shock

12. What are the diagnostic criteria for cardiogenic shock?
A. Systolic BP < 90 mmHg despite support, irrespective of signs and symptoms
B. Symptoms and sign of organ hypoperfusion, irrespective of systolic BP
C. Both refractory hypotension (systolic BP < 90 mmHg) and signs/symptoms
of organ hypoperfusion must be present

13. Still in the cath-lab ...
Although criteria for shock are not met, several hemodynamic features
configured a pre-shock scenario prone to rapid (and dramatic)
deterioration
Would you support the circulation of this patient upfront?
A. Yes
B. No
C. Systemic thrombolysis

16. The SCAI shock staging recognise two categories (A and B) which are indeed
pre-shock scenarios.
In a large validation cohort, Jetzner et al. demonstrated that patients in SCAI
shock stages A and B or pre-shock) do not appear to be particularly ill.

18. SCAI stages A-B (pre-shock) are associated with the lowest mortality but a higher
proportion of those who experience a late deterioration is going to die in
hospital.
Therefore, it is crucial to recognise patients in pre-shock (SCAI shock stages A and
B) and to monitor and treat them rapidly and appropriately.

19. Still in the cath-lab ...
Patients in pre-shock / SCAI stage A-B are prone to rapid and fatal
deterioration but laboratory and non-invasive parameters are relatively
normal.

20. How can we recognise them?
A. Volume overload
B. Initial peripheral hypoperfusion
C. Tachycardic response
D. Worsening gas-exchange
E. Large residual myocardium at risk
F. Persistent symptoms
G. Persistent hypotension
H. All these parameters aid in the decision making

21. LV-EDP is an inexpensive
and easy-to-obtain
measure of volume status
and it guided our clinical
decision-making in this
case.

22. Decision
In our case, we decided for an upfront hemodynamic support with
IABP.
We observed an immediate LV-EDP reduction.
The patient was transferred to the ICCU and rapid progressive
symptoms relief was observed.
Within a few hours, CPAP and IABP were removed.

23. Take-Home Messages
Persistent hemodynamic compromise without criteria for shock is relatively
common after anterior STEMI treatment
Routine mechanical support is not supported by evidence in cardiogenic
shock, but an upfront strategy might be useful in pre-shock settings that are
prone to rapid and fatal deterioration
It is unclear how to recognise such scenarios, but clinical features and invasive
hemodynamic parameters may guide decision making.

24. The best care of patients with
acute cardiovascular
syndromes relies on
immediate diagnosis and
decisions on treatment, some
of them life-saving.
The Clinical-Decision Making
Toolkit is THE tool to help all
practitioners make the best
bedside clinical decisions,
when managing patients with
acute cardiovascular diseases.

25. Acknowledgment
A clinical case form Dr. Claudio Montalto
 Subspecialty communities - Association for Acute
CardioVascular Care Education
 Association for Acute CardioVascular Care
 European Society of Cardiology

26. Thank You