Cardiac Pulmonary Edema and Cardiogenic Shock

Transcription

1 Cardiac Pulmonary Edema and Cardiogenic Shock 胡為雄 Frank-Starling Law Stroke Volume End-Diastolic Pressure In the normal heart, the diastolic volume (preload) is the principal force that governs the strength of ventricular contraction. Otto Frank and Ernest Starling 2 1

2 Pulmonary Edema Flow P : hydrostatic pressures π : oncotic pressures Kf : permeability constant of vessel wall δ : reflection coefficient 3 Pulmonary Edema 4 2

3 HEMODYNAMIC CHANGES PROGRESSIVE LEFT HEART FAILURE Hours 5 Cardiogenic Shock Cardiogenic shock (CS) is a state of inadequate tissue perfusion due to cardiac dysfunction, and complicates 7-10% of cases of acute myocardial infarction Without treatment, cardiogenic shock is associated with a 70-80% mortality rate, and is the leading cause of death in patients hospitalized for an acute myocardial infarction 6 3

4 Classic Criteria for Diagnosis of Cardiogenic Shock 1. Systemic Hypotension systolic arterial pressure < 80 mmhg 2. Persistent Hypotension at least 30 minutes 3. Reduced Systolic Cardiac Function Cardiac index < 1.8 x m²/min 4. Tissue Hypoperfusion Oliguria, cold extremities, confusion 5. Increased Left Ventricular Filling Pulmonary capillary wedge pressure > 18 mmhg 7 Frequency of CS Has Remained Steady Over Time Frequency of Cardiogenic Shock : 7-9% NRMI STEMI Registry N=25,311 Babaev et al JAMA :

5 Pathophysiology of Cardiogenic Shock 9 Causes of Cardiogenic Shock SHOCK Trial and Registry (N=1160) 10 5

6 11 Ventricular Septal Rupture 12 6

7 Ventricular Septal Rupture Incidence 1-2% Timing 2-5 d p MI PE murmur 90% Thrill common Echo shunt PA cath O2 step up > 9% Echo IABP Inotropic Support Surgical Timing is controversial, but usually < 48 h

8 Free Wall Rupture 15 Free Wall Rupture Incidence: 1-6% Occurs during first week after MI Classic Patient: Elderly, Female, Hypertensive Early thrombolysis reduces incidence but Late increases risk Echo: pericardial effusion, PA cath: equal diastolic pressure Treat with pericardiocentesis and early surgical repair 16 8

9 Acute Mitral Regurgitation 17 Management of Acute MR Incidence: 1-2% Echo for Differential Diagnosis: Free-wall rupture VSD Infarct Extension PA Catheter: large v wave Afterload Reduction IABP Inotropic Therapy Early Surgical Intervention 18 9

10 19 Right Ventricular Infarction: Diagnosis Clinical findings: Shock with clear lungs, Elevated JVP Kussmaul sign ECG: ST elevation in R sided leads Echo: Depressed RV function V 4 R Modified from Wellens. N Engl J Med 1999;340:

11 Management of RV Infarction Cardiogenic Shock secondary to RV Infarct has better prognosis than LV Pump Failure IV Fluid Administration IABP Dobutamine Maintain A-V Synchrony Mortality with Successful Reperfusion = 2% vs. Unsuccessful = 58% 21 The Shock Trial has been the most important study for management guidelines in patients with cardiogenic shock 22 Hochman et al NEJM 1999;341:625 11

12 The SHOCK Trial (N=302) Randomization from Apr 1993-Nov 1998 Primary Endpoint: Overall 30 day mortality Seconday Endpoints: 6 month and 1 year mortality 23 SHOCK Trial Primary and Secondary Endpoints Mortality (%) % P= % 50.3% P= % Immediate Revascularization Strategy Medical Stabilization as an Initial Strategy 0 30 Days 6 months Primary Endpoint Secondary Endpoint Hochman et al, NEJM 1999; 341:

13 PCI v. CABG in the Shock Trial 25 SHOCK Trial: Age < 75 Immediate Revascularization Strategy Medical Stabilization as an Initial Strategy 80 P < P < % % 56.8% % 65.0% Day Mortality 6 Month Mortality Hochman et al, NEJM 1999; 341:

14 P <.01 SHOCK Trial: Age > 75 Immediate Revascularization Strategy Medical Stabilization as an Initial Strategy P < % % % % % Day Mortality 6 Month Mortality Hochman et al, NEJM 1999; 341: NRMI Revascularization Rates Over Time By Age Mortality rates also decreased for those pts undergoing PCI Use of PCI increased from 27.4% to 54.4% (p < 0.001) Use of PCI was the strongest independent predictor of a lower inhospital mortality (AOR 0.46; p < 0.001) Babaev et al JAMA :

15 6 Yr Outcome of SHOCK All Patients Hochman et al JAMA 2006; 295: Cardiogenic Shock NRMI STEMI Registry (N=25,311) Mortality Rates Over Time 60.3% 47.9% P < Age, 69.4 years Women, 42.6% Hypertension, 49.7% Diabetes, 27.2% Prior MI, 23.2% Prior CHF, 15.2% Prior PCI, 9.1% Prior CABG, 12.2% Babaev et al JAMA :

16 Prognosis Is Worse With NSTEMI likely related to the extent of underlying disease 31 Multivariable Mortality Predictors Increasing age 1,2,3,4,7 and female gender 7 Lower left ventricular ejection fraction 4,6 Chronic renal insufficiency 7 Initial 6 and Final TIMI Flow grade 1 4 Lower systolic blood pressure 1 Diabetes mellitus 5 Prior MI 2 Increasing time from symptom onset to PCI 1,4 Total Occlusion of the LAD 7 Mitral regurgitation Multivessel PCI (p = 0.040) 1,4,6 1 Webb et al JACC 2003;42: Sutton Heart 2005;91:339 3 Tedesco AHJ 2003:146; Zeymer et al EHJ 2004;25:322 5 Tedesco JV Mayo Clin Proc 2003; 78:561 6 Sanborn JACC 2003:42; Klein et al AJC 2005; 96:

17 Class I ACC/AHA Guidelines for Cardiogenic Shock 1. Early revascularization, either PCI or CABG, is recommended for patients < 75 years old with ST elevation or new LBBB who develop shock unless further support is futile due to patient s wishes or unsuitability for further invasive care. 2. Fibrinolytic therapy should be administered to STEMI patients with cardiogenic shock who are unsuitable for further invasive care and do not have contraindications for fibrinolysis. 3. Echocardiography should be used to evaluate mechanical complications unless assessed by invasively 33 Class IIa ACC/AHA Guidelines for Cardiogenic Shock 1. Pulmonary artery catheter monitoring can be useful for the management of STEMI patients with cardiogenic shock. 2. Early revascularization, either PCI or CABG, is reasonable for selected patients > 75 years with ST elevation or new LBBB who develop shock < 36 hours of MI and who are suitable for revascularization that is performed < 18 hours of shock. Patients with good prior functional status who agree to invasive care may be selected for such an invasive strategy

18 35 CARDIOGENIC SHOCK MECHANICAL SUPPORT IABP Counterpulsation ECMO Ventricular assist devices 36 18

19 IABP

20 39 IABP support was associated with a in mortality: * NRMI-2 with lysis, from 67% to 49% * SHOCK Trial, from 63% to 47% 40 20

21 Contraindications to IABP Significant aortic regurgitation Abdominal aortic aneurysm Aortic dissection Uncontrolled septicemia Uncontrolled bleeding diathesis Severe bilateral peripheral vascular disease uncorrectable by peripheral angioplasty or cross-femoral surgery Bilateral femoral-popliteal bypass grafts for severe peripheral vascular disease Grossman s ACC/AHA Guidelines for Cardiogenic Shock Class I 1. IABP is recommended for STEMI patients when cardiogenic shock is not quickly reversed with pharmacological therapy. The IABP is a stabilizing measure for angiography and prompt revascularization. 2. Intra-arterial monitoring is recommended for the management of STEMI patients with cardiogenic shock

22 ECMO extracorporeal membrane oxygenation extracorporeal life support 43 ECMO Short-term cardiopulmonary support Buy time to decide the next step Recovery Transplantation Long-term device (ventricular assist device) Operation (CABG, pulmonary embolectomy,..) Give-up 44 22

23 Ventricular Assist Devices 45 Ventricular Assist Devices RVAD, LVAD, BiVAD Nonpulsatile pump Placed in parallel with RV, LV or both ventricles Adjusted to provide total systemic flow of 2-3 L/min/M 2 Complications in 50% of patients: bleeding systemic embolism 46 23

24 謝謝 24