Kardiogent shock. FYA-kursus 28. November 2006
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1 Kardiogent shock FYA-kursus 28. November 2006
2 Kardiogent shock Definiton, patogenese, mortalitet Diagnostik Mål Behandling PCI Inotropi Aortaballonpumpe LVAD (Impella, Heart Mate I og II )
3 Shock Hypovolæmisk Kardiogent Obstruktivt Hyperdynamisk (distributivt)
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5 Kardiogent shock Definition Kardial dysfunktion ledsaget af - SBP < 90 mmhg - Tegn på organhypoperfusion (oliguri etc) - Tegn på sympatikusaktivitet (koldsved, takykardi etc)
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7 Kardiogent shock Årsager Akut koronart syndrom/ami Postinfarkt VSD (1-2 %) Akut myokarditis Akut valvulær dysfunktion Endocarditis Postinfarkt papillærmuskel ruptur Lungeemboli Perikardie tamponade
8 Kardiogent shock Patofysiologi
9 Kardiogent shock Mortalitet In-hospital - Griffith et al % - Goldberg et al % - US SHOCK registry % - Goldberg et al % 30-day - TRACE-registry % - DANAMI-2 database 63%
10 European Heart Journal ;
11 Evidens
12 Goals of treatment of the patient with AHF Clinical Symptoms, clinical signs, body weight Diuresis, oxygenation Haemodynamic PCWP < 18 mmhg CO Laboratory S-electrolyte normalization Creatinine/carbamid, Bilirubin, BNP Blood glucose normalization
13 Kardiogent shock Diagnostik EKKO Kardiografi Ved koronart syndrom angiografi
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15 Kardiogent shock Behandling
16 SHOCK trial
17 SHOCK trial 30-day mortality Revasc Med p % % Total ,11 < 75 yr ,02 75 yr ,16 Hochman. N Engl J Med 1999;341:625
18 SHOCK trial 6-month mortality Revasc Med p % % Total ,027 < 75 yr , yr ,09 Hochman. N Engl J Med 1999;341:625
19 Kardiogent shock ESC ACC/AHA
20 Vasoactive drugs in AHF
21 High-dose nitrate plus low-dose furosemide versus high-dose furosemide plus low-dose nitrate in severe pulmonary oedema Primary outcome Nitrate (n=52) Furosemide (n=52) p Died 1 (2 %) 3 (6 %) 0,61 Required mechanical vetilation 7 (13 %) 21 (40 %) 0,0041 Myocardial infarction 9 (17 %) 19 (37 %) 0,047 Any adverse event 13 (25 %) 24 (46 %) 0,041 Cotter. Lancet 1998;351:389
22 ESC guidelines Vasodilators
23 Inotropic drugs in AHF
24 Inotropics Mechanism of action
25 Contractile force Calcium Sensitizers with calcium sensitizer X Cytosolic calcium concentration
26 Levosimendan (Simdax ) Ca ++ sensitizer kontraktile respons K ATP -kanal åbner vasodilatation iskæmi protektion Inodilatator CO HR SVR
27 Inodilatator treatment Short term use 24 hours OPTIME-CHF (Milrinone vs placebo) RUSSLAN (Levo vs placebo) LIDO (Levo vs dobutamine) CASINO (Levo vs dobutamine vs placebo) SURVIVE (Levo vs dobutamine) Intermittent use DICE (Dobutamine vs placebo) Continuous oral treatment Milrinone
28 OPTIME-CHF 949 patients Exacerbation of systolic heart failure Inotropic agents were not absolutely required 48 hour infusion of milrinone or placebo Primary end-point: total number of days hospitalized for cardiovascular causes within 60 days
29 OPTIME-CHF Milrinone (n=477) Placebo (n=472) p In-hospital mortality 3,8 % 2,3 % 0,19 60-day mortality 10,3 % 8,9 % 0,41 Death or readmission 35 % 35,3 % 0,92 Cuffe. JAMA 2002;287:1541
30 OPTIME-CHF Ischemic heartfailure Milrinone Placebo p (n=242) (n=243) In-hospital mortality 5,0 % 1,6 % 0,04 60-day mortality 13,3 % 10,0 % 0,21 Death or readmission 42 % 36 % 0,01 Felker. J Am Coll Cardiol 2003;41:997
31 RUSSLAN study Levosimendan vs placebo Dosis-response study 504 patients Patients with left ventricular failure due to AMI 6 hour of infusion Primary end-point was the proportion of patients developing hypotension or ischemia Secondary end-point was death for any reason over 14 days efter infusion
32 RUSSLAN study Levosimendan vs placebo Mortality at 14 days was lover with levosimendan compared with placebo 11,7 vs 19,6 % (p=0,031)
33 RUSSLAN study Levosimendan vs placebo 77,4 % Vs 68,6 % P=0,053 Moiseyev. Eur Heart J. 2002;23:1422
34 LIDO study Levosimendan vs dobutamin 203 patients with low output failure 24 hour of infusion Primary end-point at 24 hour CO 30 % PCWP 25 % Levo > Dobutamin 28 - vs 15 % of patients
35 LIDO study Levosimendan vs dobutamin Follath. Lancet. 2002;360:196
36 LIDO study Levosimendan vs dobutamin 74 % Vs 62 % P=0,029 Follath. Lancet. 2002;360:196
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40 Inotropika ESC Guidelines
41 Bayram. Am J Cardiol 2005;96[suppl]:47G-58G
42 Intraaortic balloon pump
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44 Intraaortic balloon pump Koronare bloodflow Cardiac index Indkilingstryk Hjertefrekvens Systolisk tryk Diastolisk tryk MAP Variabelt
45 Indikationer for IABP Patienter med refraktær myokardieiskæmi Kardiogent shock Infarkt, myocarditis, kardiomyopati, efterpci, farmakologisk Præoperativt Infarkt, postinfarkt VSD, papillærmuskelruptur med mitralinsufficiens Postoperativt LV dysfunktion, infarkt, efter Htx
46 Impella
47 Impella
48 Heart Mate (LVAD) Bridge to transplantation Bridge to recovery Destination therapy
49 Heart Mate I
50 Heart Mate I
51 Heart Mate I AK-behandling magnyl Vægt 1200 g Pulsativt flow Max SV = 83 ml / Max output 11 liter/min Fixed rate / auto mode (opretholder HR > 50 og SV 76 ml) Preload afhængig Relativ afterload uafhængig (ved DBP < 120 mmhg
52 Heart Mate II
53 Heart Mate II
54 Heart Mate II Vægt 400 g, volumen 124 ml Laminært flow afhængigt af Rotorhastigheden ( rpm) Λ P (aorta og venstre ventrikel) Afterload sensitiv Pulsforstærkende AK-behandling - marevan
55 15 patients Nonischemic cardiomyopathy Absence of acute myocarditis Combination therapy LVAD (Heart Mate I) Phamacologic management Enhance reverse remodeling (lisinopril, carvedilol, spironolactone, losartan) Clenbuterol (β 2 -adr receptor agonist) Birks. NEJM 2006;355:1873
56 4 patients underwent Htx 11 patients were explantated Birks. NEJM 2006;355:1873