1) Early revascularization through either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) improves survival rates in patients with cardiogenic shock compared to medical therapy alone.
2) There is ongoing debate about whether culprit vessel-only PCI or multivessel PCI is better for patients with cardiogenic shock and multivessel coronary artery disease. Current guidelines recommend culprit vessel PCI initially except in certain high-risk situations.
3) An integrated approach is needed using early revascularization, inotropic support, and potentially mechanical circulatory support, with involvement of multiple specialists. Cardiogenic shock continues to pose major challenges in acute cardiac care.
3. 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
10. 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
12. 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
Ischemia
LV
dysfunction
Hypotension
X
13. STEMI with MVD & cardiogenic shock:
culprit or multivessel PCI?
In hospital outcomes shock pts.
1 vessel
PCI
Multi-
vessel PCI
p
value
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 mortality
National Cardiovascular Data Registry
MA Cavender et al.
Am J Cardiol 2009;104: 507-513
Multi- vs. 1-vessel PCI
14. 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
15. 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%
16. PPCI in STEMI with Resuscitated Cardiac Arrest,
and Cardiogenic Shock
D Mylotte et al.
J Am Coll Cardiol Intv 2013;6:115–25
17. Culprit-only vs. multivessel PCI in cardiogenic
shock complicating STEMI
Mortality MACE
JH Yang et al.
Crit Care Med 2014; 42:17–25
25. • 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