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

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

6. SHOCK CARDIOGENICO CURVAS DE PRESION Y DE PERFUSION CORONARIA

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

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

16. A C P

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

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

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.

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

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?

32. PAZ MUNDIAL