Kardiogent shock. FYA-kursus 28. November 2006

Transcription

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