- The document discusses cardiogenic shock, which is a clinical condition defined by hypotension and signs of hypoperfusion due to impaired cardiac function, usually caused by acute myocardial infarction. - Key treatments discussed for cardiogenic shock include early revascularization (within 18 hours) for younger patients, use of an intra-aortic balloon pump, and inotropic support. Fibrinolysis may be considered when intervention is contraindicated. - Factors such as right ventricular infarction, arrhythmias, and mechanical complications also warrant consideration in management of cardiogenic shock. Early reperfusion and hemodynamic support are emphasized.

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. SHOCK CARDIOGENICO DEFINICION: EVIDENCIA CLINICA DE HIPOPERFUSION CON PRESION ARTERIAL SISTOLICA < 90 mm Hg > 30 min NECESIDAD DE TERAPIA PARA MANTENER PAS > DE 90 mmHg IC < 2.2 L/ min / m2 PCP (en cuña) > 15 mm Hg THE SHOCK TRIAL JAMA 2001; 285: 190-2

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. SHOCK CARDIOGENICO CAUSAS EXTENSION DEL IMA (40% VI) IMA DE VENTRICULO DERECHO RM AGUDA (RUPTURA DE MP) CIV AGUDA RUPTURA DE PARED LIBRE TAPONAMIENTO CARDIACO

5. SHOCK CARDIOGENICO PRIMER RX LIMITAR TAMAÑO DEL IMA RESTABLECER REPERFUSION CORONARIA CONTROLAR RESPUESTAS INJURIOSAS ACTIVIDAD SIMPATICA SISTEMA SRA RESISTENCIA PERIFERICA POST CARGA

6. SHOCK CARDIOGENICO CURVAS DE PRESION Y DE PERFUSION CORONARIA

7. SHOCK CARDIOGENICO IMA Injuria Miocardica Irreversible 15 - 20 min Injuria completa area de riesgo 4 - 6 Hrs Mayor magnitud del daño 2 - 3 Hrs Restauración del flujo para obtener mayor beneficio 1 - 2 Hrs Hipóteis de arteria abierta flujo normal mortalidad Tamaño de infarto lo anterior mas colaterales

8. Emergency Management of Complicated STEMI Administer Fluids Blood transfusions Cause-specific interventions Consider vasopressors 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 Administer Furosemide IV 0.5 to 1.0 mg/kg Morphine IV 2 to 4 mg Oxygen /intubation as needed Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP greater than 100 mm Hg Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to 100 mm Hg and signs/symptoms of shock present Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70 to 100 mm Hg and no signs/symptoms of shock 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.

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. 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). systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline severe bradycardia (< 50 bpm) tachycardia (> 100 bpm) or suspected RV infarction. When NOT to give Nitroglycerin SHOCK CARDIOGENICO IMA

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. SHOCK CARDIOGENICO < 75 AÑOS ST BCRI SHOCK < 36 HS DEL IMA INTERVENCION < 18 HORAS REVASCULARIZACION TEMPRANA CLASE IA BALON DE CONTRAPULSACION AORTICO (IABP) 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

14. SHOCK CARDIOGENICO STEMI + PAS < 90 mm Hg PAm < 30 mm Hg CLASE IB BALON INTRAORTICO DE CONTRAPULSACION (IABP) STEMI + ESTADO DE BAJO GASTO CARDIACO STEMI + SHOCK SIN RESPUESTA FARMACOLOGICA STEMI + DOLOR PRECORDIAL ISQUEMIA RECURRENTE INESTABILIDAD HEMODINAMICA FUNCION VENTRICULAR DEPRIMIDA AREA MIOCARDICA DE RIESGO GRANDE IACB + CAT + CIRUGIA 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

15. SHOCK CARDIOGENICO STEMI + TAQUICARDIA VENTRICULAR POLIMORFA CLASE II a BALON INTARORTICO DE CONTRAPULSACION (IABP) STEMI + ICC

16. A C P

17. ACP PRIMARIA O DE RESCATE EN STEMI: DEBE REALIZARSE –IB- en pacientes severa (ICC) (Killip clase 3) con Sx < 12 horas La ACP Primaria debe realizarse -IA- en pacientes < 75 años con elevación ST o BCRI SHOCK <36 horas post MI, ACP realizable <primeras 18 horas del shock. En pacientes >75 años: - IIa B- SHOCK CARDIOGENICO IMA

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

19. FIBRINOLÍSIS REPERFUSIÓN

20. SHOCK CARDIOGENICO FIBRINOLISIS CUANDO INTERVENCION ESTA CONTRAINDICADA MONITOREO HEMODINAMICO INTRAARTERIAL ECOCARDIOGRAFIA (EVIDENCIAR COMPLICACIONES MECANICAS) 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

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. SHOCK CARDIOGENICO CATETER PULMONAR REVASCULARIZACION TEMPRANA < 75 AÑOS ST BCRI SHOCK < 36 HS DEL IMA INTERVENCION < 18 HORAS > 75 AÑOS INDICACION IIaB 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

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. SHOCK CARDIOGENICO EKG + V4R ECOCARDIOGRAMA CLASE I SOSPECHA DE IMA VD STEMI + INESTABILIDAD HEMODINAMICA INFERIOR REPERFUSION TEMPRANA ACP CORREGIR BRADICARDIA Y ASINCRONIA AV PRECARGA DERECHA CARGA INICAL RESPUESTA POSITIVA OPTIMIZAR VOLUMEN PV < NORMAL POSCARGA DERECHA OPTIMIZAR FUNCION V IZQ. ASISTENCIA INOTROPICA CUANDO SOBRECARGA DE VOLUMEN ES INSUFICIENTE 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

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. SHOCK CARDIOGENICO RUPTURA DE MUSCULO PAPILAR CIRUGIA URGENTE REGURGITACION MITRAL CONCOMITANTE CABG 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

28. SHOCK CARDIOGENICO CIRUGIA URGENTE RUPTURA SEPTAL O DE PARED LIBRE CABG 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

29. SHOCK CARDIOGENICO STEMI + AV + ARRITMIA INTRATABLE Y/O SHOCK ANEURISMECTOMIA + CABC 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

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. Atacado de fiebres un indio de Loja llamado Pedro de Leyva, bebió, para calmar los ardores de la sed, del agua de un remanso, en cuyas orillas crecían algunos árboles de quina … Con su descubrimiento vino a Lima y lo comunicó a un jesuita, el que, realizando la feliz curación de la virreina, prestó a la Humanidad mayor servicio que el fraile que inventó la pólvora. Mendiburo dice que, al principio, encontró el uso de la quina fuerte oposición en Europa, y que en Salamanca se sostuvo que caía en pecado mortal el médico que la recetaba, pues sus virtudes eran debidas a pacto de los peruanos con el diablo.

32. PAZ MUNDIAL