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UNIVERSIDAD RICARDO PALMA FACULTAD DE MEDICINA HUMANA V CURSO INTERNACIONAL DE ACTUALIZACIÓN EN MEDICINA Y CIRUGIA – IV JORNADA DE EDUCACIÓN MÉDICA UNIVERSITARIA CONFERENCIA: “ SHOCK CARDIOGÉNICO” DOCTOR ALFREDO PALACIO I N C A P  U E E S INSTITUTO NACIONAL DE CARDIOLOGIA  FACULTAD DE MEDICINA  “ ALFREDO PALACIO”  “ENRIQUE ORTEGA MOREIRA” GUAYAQUIL – ECUADOR
SHOCK CARDIOGENICO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],THE SHOCK TRIAL JAMA 2001; 285: 190-2
SHOCK CARDIOGENICO *   SIGUE SIENDO LA 1ª CAUSA DE MUERTE – IH – EN EL IMA (TAMI) I TRIAL  CIRCULATION 1988; 77: 1090-90 NEJM 1991; 325: 1117-22 JACC 1992; 20: 1982-9 20-50% 70 % + / IABP SOBREVIDA – IH - INTRAHOSPITALARIA 40%  * 80% MORTALIDAD 5 – 7 % 20% PREVALENCIA  EN IMA REPERFUSION PREREPERFUSION
SHOCK CARDIOGENICO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
SHOCK CARDIOGENICO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
SHOCK CARDIOGENICO CURVAS DE PRESION Y DE PERFUSION CORONARIA
SHOCK CARDIOGENICO IMA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Emergency Management of Complicated STEMI ,[object Object],[object Object],[object Object],[object Object],[object Object],Arrhythmia Bradycardia Tachycardia Systolic BP Greater than 100 mm Hg Systolic BP  70 to 100 mm Hg NO signs/symptoms of shock Systolic BP 70 to 100 mm Hg Signs/symptoms of shock Systolic BP  l ess than 70 mm Hg Signs/symptoms of shock Dobutamine 2 to 20 mcg/kg per minute IV Low Output - Cardiogenic Shock Nitroglycerin 10 to 20 mcg/min IV Dopamine 5 to 15 mcg/kg per minute  IV Norepinephrine 0.5 to 30  mc g/min IV Hypovolemia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],First line of action Second line of action Third line of action ACC/AHA Guidelines for Patients With ST-Elevation Myocardial Infarction Check Blood Pressure Clinical signs:  Shock, hypoperfusion, congestive heart failure, acute pulmonary edema Most likely major underlying disturbance? Further diagnostic/therapeutic considerations (should be considered in nonhypovolemic shock) Diagnostic   Therapeutic ♥  Pulmonary artery catheter   ♥  Intra-aortic balloon pump ♥  Echocardiography   ♥  Reperfusion/revascularization ♥  Angiography for MI/ischemia   ♥  Additional diagnostic studies Acute Pulmonary Edema Check Blood Pressure Systolic BP  Greater than 100 mm Hg   and not less than 30 mm Hg  below baseline ACE Inhibitors Short-acting agent such as captopril (1 to 6.25 mg) Circulation 2000;102(suppl I):I-172-I-216.
All-Cause Mortality Years Probability of Event ACE-I 2995 2250 1617 892 223 Placebo 2971 2184 1521 853 138 Flather MD, et al.  Lancet . 2000;355:1575–1581 OR: 0.74 (0.66–0.83) ACE-I: 702/2995 (23.4%) Placebo: 866/2971 (29.1%) TRACE Echocardiographic EF    35% AIRE Clinical and/or radiographic signs of HF SAVE Radionuclide EF    40% 0 0.05 0.1 0.15 0.2 0.25 0.3 0 1 2 3 0.35 0.4 4 ACE-I Placebo
Nitrates should not be administered to patients with: Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48  hours for tadalafil).  ,[object Object],[object Object],[object Object],[object Object],When NOT to give Nitroglycerin SHOCK CARDIOGENICO IMA
EVIDENCE GRADING A B C BENEFICIAL  HARMFUL RANDOMIZED  EXPERT OPINION SHOCK CARDIOGENICO IMA
Cardiogenic Shock 1-2 vessel CAD Moderate 3-vessel CAD Severe 3-vessel CAD Left main CAD PCI IRA PCI IRA Immediate CABG Staged Multivessel PCI Staged CABG Cannot be performed Early Shock, Diagnosed on Hospital Presentation Delayed Onset Shock Echocardiogram to Rule Out Mechanical Defects Cardiac Catheterization and Coronary Angiography IABP Fibrinolytic therapy if   all of  the following   are present:   1. Greater than 90 minutes to PCI 2. Less than 3 hours post STEMI  onset 3.  No contraindications Arrange prompt   transfer   to invasive procedure-capable center Arrange rapid transfer to invasive procedure-capable center PCI for Cardiogenic Shock
SHOCK CARDIOGENICO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],CLASE IA  ,[object Object],I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A
SHOCK CARDIOGENICO ,[object Object],[object Object],CLASE IB BALON INTRAORTICO DE CONTRAPULSACION (IABP) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],CLASE IC I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
SHOCK CARDIOGENICO ,[object Object],CLASE II a BALON INTARORTICO DE CONTRAPULSACION (IABP) ,[object Object]
A C P
ACP PRIMARIA O DE RESCATE EN STEMI: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],SHOCK CARDIOGENICO IMA
  APC POSTERIOR A FIBRINOLISIS APC debe ser realizada en  pacientes con:   Evidencia objetiva de   IMA recurrente Isquemia miocardica moderada o severa ,  ya   sea espontanea o provocada ,   durante la recuperacion STEMI Shock   cardiogenico o inestabilidad hemodinamica .   SHOCK CARDIOGENICO IMA
FIBRINOLÍSIS REPERFUSIÓN
SHOCK CARDIOGENICO ,[object Object],[object Object],[object Object],[object Object],[object Object],CLASE I I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
SHOCK CARDIOGENICO THE SHOCK TRIAL (P=0.11) (P<0.03) REVASCULARIZACION 66.4% 53.3% 6 A 12 MESES 50.0% 46.7% MORTALIDAD 30 DIAS  ESTABILIZACION MEDICA INICAL REVASCULARIZACION DE EMERGENCIA
SHOCK CARDIOGENICO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],CLASE II I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A
Evidence-Based Approach to Need for  Catheterization and Revascularization After STEMI STEMI Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy Cath  Performed No Cath  Performed EF greater  than 0.40 EF less  than 0.40 EF less  than 0.40 EF greater  than 0.40 High - Risk Features † No High - Risk Features † No High - Risk Features † High - Risk Features † Functional  Evaluation ECG Interpretable ECG Uninterpretable Able to Exercise Unable to Exercise Submaximal Exercise Test Before Discharge Symptom - Limited Exercise Test Before or After Discharge Pharmacological Stress Nuclear Scan Dobutamine Echo Clinically Significant Ischemia* No Clinically Significant Ischemia* Medical Therapy Revascularization as  Indicated Catheterization and  Revascularization as  Indicated Catheterization and  Revascularization as  Indicated Able to Exercise Exercise  Echo Exercise  Nuclear STEMI Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy Cath  Performed No Cath  Performed EF greater  than 0.40 EF less  than 0.40 EF less  than 0.40 EF greater  than 0.40 High - Risk Features No High - Risk Features No High - Risk Features High - Risk Features Functional  Evaluation ECG Interpretable ECG Uninterpretable Able to Exercise Unable to Exercise Submaximal Exercise Test Before Discharge Symptom - Limited Exercise Test Before or After Discharge Pharmacological Stress Adenosine or Dipyridamole Dobutamine Echo Clinically Significant Ischemia No Clinically Significant Ischemia Medical Therapy Revascularization as  Indicated Catheterization and  Revascularization as  Indicated Catheterization and  Revascularization as  Indicated Able to Exercise Exercise  Echo Exercise  Nuclear
Right Ventricular Infarction Clinical findings: Shock with clear lungs, elevated JVP Kussmaul sign Hemodynamics:  Increased RA pressure (y descent) Square root sign in RV tracing ECG: ST elevation in R sided leads Echo: Depressed RV function Rx: Maintain RV preload Lower RV afterload (PA---PCW) Inotropic support Reperfusion V 4 R  Modified from Wellens. N Engl J Med 1999;340:381.
SHOCK CARDIOGENICO ,[object Object],[object Object],CLASE I SOSPECHA DE IMA VD  STEMI + INESTABILIDAD HEMODINAMICA INFERIOR ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
Ventricular Septal Rupture Mitral Regurgitation (Pap. M. dysfunction) Incidence 1-2%   1-6% 1-2% Timing 3-5 d p MI   3-6 d p MI 3-5 d p MI Phy Exam murmur 90%   JVD, EMD murmur 50% Thrill Common   No Rare Echo Shunt   Peric. Effusion Regurg. Jet PA cath O 2  step up   Diast Press Equal. c-v wave in PCW Images:Courtesy of W D Edwards (Mayo Foundation) Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426. Free Wall Rupture
SHOCK CARDIOGENICO ,[object Object],[object Object],REGURGITACION MITRAL ,[object Object],Mitral Regurgitation (Pap. M. dysfunction) I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
SHOCK CARDIOGENICO ,[object Object],RUPTURA SEPTAL O DE PARED LIBRE ,[object Object],Ventricular Septal Rupture I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
SHOCK CARDIOGENICO ,[object Object],[object Object],ANEURISMA VENTRICULAR I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
ICD Implantation After STEMI One Month After STEMI;  No Spontaneous VT or VF 48 hours post-STEMI EF < 0.30 EPS Yes + NEJM 349:  1836,2003 EF 0.31  -  0.40 No EF > 0.40 - No ICD. Medical Rx Additional Marker of  Electrical Instability?
[object Object],[object Object]
PAZ MUNDIAL

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S H O C K C A R I O G E N I C O2

  • 1. UNIVERSIDAD RICARDO PALMA FACULTAD DE MEDICINA HUMANA V CURSO INTERNACIONAL DE ACTUALIZACIÓN EN MEDICINA Y CIRUGIA – IV JORNADA DE EDUCACIÓN MÉDICA UNIVERSITARIA CONFERENCIA: “ SHOCK CARDIOGÉNICO” DOCTOR ALFREDO PALACIO I N C A P U E E S INSTITUTO NACIONAL DE CARDIOLOGIA FACULTAD DE MEDICINA “ ALFREDO PALACIO” “ENRIQUE ORTEGA MOREIRA” GUAYAQUIL – ECUADOR
  • 2.
  • 3. SHOCK CARDIOGENICO * SIGUE SIENDO LA 1ª CAUSA DE MUERTE – IH – EN EL IMA (TAMI) I TRIAL CIRCULATION 1988; 77: 1090-90 NEJM 1991; 325: 1117-22 JACC 1992; 20: 1982-9 20-50% 70 % + / IABP SOBREVIDA – IH - INTRAHOSPITALARIA 40% * 80% MORTALIDAD 5 – 7 % 20% PREVALENCIA EN IMA REPERFUSION PREREPERFUSION
  • 4.
  • 5.
  • 6. SHOCK CARDIOGENICO CURVAS DE PRESION Y DE PERFUSION CORONARIA
  • 7.
  • 8.
  • 9. All-Cause Mortality Years Probability of Event ACE-I 2995 2250 1617 892 223 Placebo 2971 2184 1521 853 138 Flather MD, et al. Lancet . 2000;355:1575–1581 OR: 0.74 (0.66–0.83) ACE-I: 702/2995 (23.4%) Placebo: 866/2971 (29.1%) TRACE Echocardiographic EF  35% AIRE Clinical and/or radiographic signs of HF SAVE Radionuclide EF  40% 0 0.05 0.1 0.15 0.2 0.25 0.3 0 1 2 3 0.35 0.4 4 ACE-I Placebo
  • 10.
  • 11. EVIDENCE GRADING A B C BENEFICIAL HARMFUL RANDOMIZED EXPERT OPINION SHOCK CARDIOGENICO IMA
  • 12. Cardiogenic Shock 1-2 vessel CAD Moderate 3-vessel CAD Severe 3-vessel CAD Left main CAD PCI IRA PCI IRA Immediate CABG Staged Multivessel PCI Staged CABG Cannot be performed Early Shock, Diagnosed on Hospital Presentation Delayed Onset Shock Echocardiogram to Rule Out Mechanical Defects Cardiac Catheterization and Coronary Angiography IABP Fibrinolytic therapy if all of the following are present: 1. Greater than 90 minutes to PCI 2. Less than 3 hours post STEMI onset 3. No contraindications Arrange prompt transfer to invasive procedure-capable center Arrange rapid transfer to invasive procedure-capable center PCI for Cardiogenic Shock
  • 13.
  • 14.
  • 15.
  • 16. A C P
  • 17.
  • 18. APC POSTERIOR A FIBRINOLISIS APC debe ser realizada en pacientes con: Evidencia objetiva de IMA recurrente Isquemia miocardica moderada o severa , ya sea espontanea o provocada , durante la recuperacion STEMI Shock cardiogenico o inestabilidad hemodinamica . SHOCK CARDIOGENICO IMA
  • 20.
  • 21. SHOCK CARDIOGENICO THE SHOCK TRIAL (P=0.11) (P<0.03) REVASCULARIZACION 66.4% 53.3% 6 A 12 MESES 50.0% 46.7% MORTALIDAD 30 DIAS ESTABILIZACION MEDICA INICAL REVASCULARIZACION DE EMERGENCIA
  • 22.
  • 23. Evidence-Based Approach to Need for Catheterization and Revascularization After STEMI STEMI Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy Cath Performed No Cath Performed EF greater than 0.40 EF less than 0.40 EF less than 0.40 EF greater than 0.40 High - Risk Features † No High - Risk Features † No High - Risk Features † High - Risk Features † Functional Evaluation ECG Interpretable ECG Uninterpretable Able to Exercise Unable to Exercise Submaximal Exercise Test Before Discharge Symptom - Limited Exercise Test Before or After Discharge Pharmacological Stress Nuclear Scan Dobutamine Echo Clinically Significant Ischemia* No Clinically Significant Ischemia* Medical Therapy Revascularization as Indicated Catheterization and Revascularization as Indicated Catheterization and Revascularization as Indicated Able to Exercise Exercise Echo Exercise Nuclear STEMI Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy Cath Performed No Cath Performed EF greater than 0.40 EF less than 0.40 EF less than 0.40 EF greater than 0.40 High - Risk Features No High - Risk Features No High - Risk Features High - Risk Features Functional Evaluation ECG Interpretable ECG Uninterpretable Able to Exercise Unable to Exercise Submaximal Exercise Test Before Discharge Symptom - Limited Exercise Test Before or After Discharge Pharmacological Stress Adenosine or Dipyridamole Dobutamine Echo Clinically Significant Ischemia No Clinically Significant Ischemia Medical Therapy Revascularization as Indicated Catheterization and Revascularization as Indicated Catheterization and Revascularization as Indicated Able to Exercise Exercise Echo Exercise Nuclear
  • 24. Right Ventricular Infarction Clinical findings: Shock with clear lungs, elevated JVP Kussmaul sign Hemodynamics: Increased RA pressure (y descent) Square root sign in RV tracing ECG: ST elevation in R sided leads Echo: Depressed RV function Rx: Maintain RV preload Lower RV afterload (PA---PCW) Inotropic support Reperfusion V 4 R Modified from Wellens. N Engl J Med 1999;340:381.
  • 25.
  • 26. Ventricular Septal Rupture Mitral Regurgitation (Pap. M. dysfunction) Incidence 1-2% 1-6% 1-2% Timing 3-5 d p MI 3-6 d p MI 3-5 d p MI Phy Exam murmur 90% JVD, EMD murmur 50% Thrill Common No Rare Echo Shunt Peric. Effusion Regurg. Jet PA cath O 2 step up Diast Press Equal. c-v wave in PCW Images:Courtesy of W D Edwards (Mayo Foundation) Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426. Free Wall Rupture
  • 27.
  • 28.
  • 29.
  • 30. ICD Implantation After STEMI One Month After STEMI; No Spontaneous VT or VF 48 hours post-STEMI EF < 0.30 EPS Yes + NEJM 349: 1836,2003 EF 0.31 - 0.40 No EF > 0.40 - No ICD. Medical Rx Additional Marker of Electrical Instability?
  • 31.

Editor's Notes

  1. EL PRIMER PASO AL MANEJO DE SHOCK CARDIOGENO ES SU PREVENCIÓN MEDIANTE LA LIMITACIÓN DEL TAMAÑO DEL IMA, RESTABLECER LA PERFUSIÓN CORONARIA Y CONTROLANDO LAS RESPUESTAS INJURIOSAS
  2. La perfusión coronaria ocurre el momento de máximo volumen de VI y de mínima resistencia del mismo. Las 2 Presiones coronarias y --- generan perfusión contra la baja resistencia Diastólica En sistole las presiones de A– y VI se igualan el VI se contrae no hay perfusión + volumen VI. Si la presión coronaria cae bajo la Presión aórtica, el flujo se mantiene por auto refulación. ------ Luego ISQUEMIA = ------ CONTRACTILIDAD PFVI Bajo Gas—o SHOCK P P ISQUEMIA
  3. The emergency management of patients with cardiogenic shock (CS), acute pulmonary edema (PE) or both is outlined. Las complicaciones que demandan emergencias ee el IMA mas comunmente son Edema Pulmonar Agudo, Hipovolemia, Shoc Cadiógeno y Arritmias: Si la PAS está 70 a 100 mm Hg, Pero sin Sx ni Sg de ShocK: Dobutamina 2 a 20 mcg/kg/min IV. Si la PAS esta &lt;70 a 100 mm Hg con Sx y Sx de Shock: Dopamine 5 a 18 mcg/Kg/min IV Si la PAS esta &lt;70 mm Hg: Norepinefrina 5 a 30 mcg/Kg/min IV. Si la PAS &gt;100mm Hg: NTG. Si la PAS &gt;100 mmHg ( y hasta 30 mmhg de la PA basal): Inhibidores e la ECA. El siguiente paso medidas DX y RX
  4. Desde e Etudio SOLVD con el Enalapril se ha prbado que los inhibidores de la ECA mejoran mortalidad en presencia de bajo gasto o ICC. Lo confirman el SAVE, el AIRE, el TRACE.
  5. Seguimos el mismo abordaje Probabilístico de 4 CLASES de INDICACIONES de lo Beneficioso a lo Perjudicial con 3 niveles de Evidencia.
  6. Pacientes e Shock Cardíogenico de Presentación Temprana o TARDIA ------ IABP ---- ANYLA ---- REN---LIZA Ahora, en la Presentación Temprana ----- FIBRINOLISIS, si es que &gt;90¨ ( sin APC ) &lt; 3 HORAS del IMA 1 – 2 Vasos 3 vasos Modea--- 3 vasos o tienen A P C ARI Otros Vasos
  7. This algorithm shows the treatment paths for patients who initially undergo a primary invasive strategy, receive fibrinolytic therapy, or do not undergo reperfusion therapy for STEMI. Patients who have not undergone a primary invasive strategy and have no high risk features should undergo functional evaluation using one of the noninvasive tests shown. When clinically significant ischemia is detected, patients should undergo catheterization and revascularization as indicated; if no clinically significant ischemia is detected, medical therapy is prescribed post-STEMI.
  8. Algorithm to aid in selection of implantable cardioverter/defibrillator (ICD) in patients with STEMI and diminished ejection fraction (EF). The appropriate management path is selected based upon left ventricular ejection fraction (LVEF) measured at least one month after STEMI. These criteria, that are based on the published data, form the basis for the full-text guidelines in section 7.7.1.5. All patients, whether an ICD is implanted or not, should receive medical therapy as outlined in the full-text guidelines.