La Terapia dello Shock Cardiogeno, Up Date 2016

Transcription

1 UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1-Emodinamica Scompenso Cardiaco Avanzato La Terapia dello Shock Cardiogeno, Up Date 2016 Fabrizio Oliva CONVENTION DELLA CARDIOLOGIA LOMBARDA 2016 Grand HotelGardone, Gardone Aprile 2016

2 Presenter Disclosure Information: Grant/Research support: Orion Pharma,Servier Italia Speaker s bureau: Norvartis Pharmaceuticals, Orion Pharma Consultant/Advisory board: St Jude Medical

3 Epidemiologia e Prognosi Flow Chart Operativa Shock Cardiogeno Topics Rivascolarizzazione Timing PCI vs CABG Multivessel vs Culprit Terapia Medica Supporto Meccanico

4 UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1-Emodinamica

5 UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1-Emodinamica

6 Harjola VP

7 Harjola VP EJHF 2015

8 De Luca et al - EJHF 2015

9 IN-HF Outcome Acute HF: All-cause mortality by clinical profile at entry 38.1% 32.2% 24.0% 23.4% 22.6% 22.6% 15.8% (n. 1855) (n. 239) (n. 42) (n. 501) (n. 95) (n. 164) (n. 814) Oliva et al EJHF 2012

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11 Harjola EJHF 2015 Early Risk Stratification

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13 Cardiogenic Shock (CS) in AMI Pathophysiology-Current Concept

14 Trattamento dello Shock che complica l Infarto Miocardico Thiele H et al,, Eur Heart J 2015 ESC Guidelines on STEMI, Eur Heart J 2012, ESC Guidelines on myocardial rev. Eur Heart J 2014

15 Trattamento dello Shock che complica NonSTEMI ESC Guidelines on NonSTEMI, Eur Heart J Sep 2015

16 UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1-Emodinamica Rivascolarizzazione Timing

17 Timing of Revascularization JACC 2003

18 UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1-Emodinamica Rivascolarizzazione PCI vs CABG

19 CABG vs PCI? Although the mode of revascularization was not randomized in the SHOCK TRIAL, survival was similar in patients treated with PCI and CABG CABG should be reserved for patients with mechanical complications or coronary anatomy not amenable to PCI who have ongoing CS White HD, Assmann SF, Sanborn TA, et al. Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial. Circulation. 2005;112:

20 UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1-Emodinamica Rivascolarizzazione Culprit vs Multivessel

21 Culprit vs Multivessel Mylotte D JACC Int 2013

22 Immediate multivessel percutaneous coronary intervention versus culprit lesion intervention in patients with acute myocardial infarction complicated by cardiogenic shock: results of the ALKK-PCI registry. Zeymer U, Hochadel M, Thiele H, Andresen D, Schühlen H, Brachmann J, Elsässer A, Gitt A, Zahn R Aims: Current guidelines recommend immediate multivessel percutaneous coronary intervention (PCI) in patients with cardiogenic shock, despite the lack of randomised trials. We sought to investigate the use and impact on outcome of multivessel PCI in current practice in cardiogenic shock in Germany. Methods and results: Between January 2008 and December 2011 a total of 735 consecutive patients with acute myocardial infarction, cardiogenic shock and multivessel coronary artery disease underwent (Culprit-Shock immediate PCI in 41 hospitals Trial, in Germany. NCT ) Of these, 173 (23.5%) patients were treated with immediate multivessel PCI. The acute success of PCI with respect to TIMI 3 flow did not differ between the groups (82.5% versus 79.6%). In-hospital mortality with multivessel PCI and culprit lesion PCI was 46.8% and 35.8%, respectively. In multivariate analysis multivessel PCI was associated with an increased mortality (odds ratio 1.5; 95% confidence interval ). Conclusions: In current clinical practice in Germany multivessel PCI is used only in one quarter of patients with cardiogenic shock treated with primary PCI. We observed an adverse effect of immediate multivessel PCI. Therefore, a randomised trial is needed to determine the definitive role of multivessel PCI in cardiogenic shock. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology, August 2014

23 UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1-Emodinamica Shock TERAPIA FARMACOLOGICA

24 Inotropic/Vasopressor support

25 Werdan K Inotropic/Vasopressor support

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28 Russ et al Crit Care Med 2007

29 Munich, January 22th, 2016 Recommendations for the use of levosimendan in Acute Heart Failure and Cardiogenic Shock complicating ACS: a review and expert consensus opinion Type I: ACS + congestion, BP > 120mmHg, HR increased Type II: ACS+ low or normal HR, worsening congestion, BP decreasing Type III: Large infarction, congestion/ pulmonary oedema, BP decreasing Type IV: Large complicated infarction, BP decreases, diuresis decreases, - CS immediately at entry or at early hospitalisation No benefits An option An option Should be considered Niemen et Al Submitted

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33 UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1-Emodinamica Shock e IMA SUPPORTO MECCANICO

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35 ESC Guidelines Myocardial Revascularization 2014 N Eng J Med 2012; 367: Lancet 2013; 382;

36 BUT Scenario: CS complicating AMI, early revascularization planned. Slightly lower mortality compared other trials and registries. Exclusion of AMI mechanical complications 87% device implantion after procedure High rate of catecholamine use (90%) may offset the potential benefit of IABP. Exclusion criterion of onset shock > 12 h selected for a disease more amenable to revascularization. Benefit in severe CS is still unsettled

37 UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1-Emodinamica Trattatamento dello Shock Supporto Circolatorio Meccanico

38 Seyfarth JACC 2008

39 Sheu J-J Crit Care Med 2010

40 Trends in MCS in AMI with CS Strong evidence suggests that IABP does not reduce mortality Impella CP could be a option in pts that require more than LD vasopressor or multivessel PCI Reserve ECMO for pts you cannot oxygenate or do not tolerate Impella due to emolysis MCS should be initiated as early as possible to prevent permanent organ dysfunction

41 Studio AltSHOCK FLOW CHART

42 Dott.Fabrizio Oliva ASST Niguarda Milano Dott.Michele Senni ASST Papa Giovanni XXIII Dott. Emanuele Catena ASST Fatebenefratelli Sacco Dott. Elena Corrada Istituto Clinico Humanitas Prof. Stefano Carugo ASST Santi Paolo e Carlo Dott. Federico Pappalardo Ospedale San Raffaele Dott. Francesco Gentile ASST Nord Milano Ospedale Bassini Dott. Marco Negrini ASST Fatebenefratelli Sacco Dott. Antonio Mafrici ASST Santi Paolo e Carlo

43 THINK BIG. START SMALL. MOVE FAST Grazie per l attenzione