Kardiogent shock FYA-kursus 28. November 2006
Kardiogent shock Definiton, patogenese, mortalitet Diagnostik Mål Behandling PCI Inotropi Aortaballonpumpe LVAD (Impella, Heart Mate I og II )
Shock Hypovolæmisk Kardiogent Obstruktivt Hyperdynamisk (distributivt)
Kardiogent shock Definition Kardial dysfunktion ledsaget af - SBP < 90 mmhg - Tegn på organhypoperfusion (oliguri etc) - Tegn på sympatikusaktivitet (koldsved, takykardi etc)
Kardiogent shock Årsager Akut koronart syndrom/ami Postinfarkt VSD (1-2 %) Akut myokarditis Akut valvulær dysfunktion Endocarditis Postinfarkt papillærmuskel ruptur Lungeemboli Perikardie tamponade
Kardiogent shock Patofysiologi
Kardiogent shock Mortalitet In-hospital - Griffith et al 1954 80% - Goldberg et al 1975-1988 80% - US SHOCK registry 1998 70% - Goldberg et al 1990-96 69% 30-day - TRACE-registry 1990-92 62% - DANAMI-2 database 63%
European Heart Journal 2005 26; 384-416
Evidens
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
Kardiogent shock Diagnostik EKKO Kardiografi Ved koronart syndrom angiografi
Kardiogent shock Behandling
SHOCK trial
SHOCK trial 30-day mortality Revasc Med p % % Total 47 56 0,11 < 75 yr 41 57 0,02 75 yr 75 53 0,16 Hochman. N Engl J Med 1999;341:625
SHOCK trial 6-month mortality Revasc Med p % % Total 50 63 0,027 < 75 yr 45 65 0,002 75 yr 79 56 0,09 Hochman. N Engl J Med 1999;341:625
Kardiogent shock ESC ACC/AHA
Vasoactive drugs in AHF
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
ESC guidelines Vasodilators
Inotropic drugs in AHF
Inotropics Mechanism of action
Contractile force Calcium Sensitizers with calcium sensitizer X Cytosolic calcium concentration
Levosimendan (Simdax ) Ca ++ sensitizer kontraktile respons K ATP -kanal åbner vasodilatation iskæmi protektion Inodilatator CO HR SVR
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
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
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
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
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
RUSSLAN study Levosimendan vs placebo Mortality at 14 days was lover with levosimendan compared with placebo 11,7 vs 19,6 % (p=0,031)
RUSSLAN study Levosimendan vs placebo 77,4 % Vs 68,6 % P=0,053 Moiseyev. Eur Heart J. 2002;23:1422
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
LIDO study Levosimendan vs dobutamin Follath. Lancet. 2002;360:196
LIDO study Levosimendan vs dobutamin 74 % Vs 62 % P=0,029 Follath. Lancet. 2002;360:196
Inotropika ESC Guidelines
Bayram. Am J Cardiol 2005;96[suppl]:47G-58G
Intraaortic balloon pump
Intraaortic balloon pump Koronare bloodflow Cardiac index Indkilingstryk Hjertefrekvens Systolisk tryk Diastolisk tryk MAP Variabelt
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
Impella
Impella
Heart Mate (LVAD) Bridge to transplantation Bridge to recovery Destination therapy
Heart Mate I
Heart Mate I
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
Heart Mate II
Heart Mate II
Heart Mate II Vægt 400 g, volumen 124 ml Laminært flow afhængigt af Rotorhastigheden (8000-15000 rpm) Λ P (aorta og venstre ventrikel) Afterload sensitiv Pulsforstærkende AK-behandling - marevan
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
4 patients underwent Htx 11 patients were explantated Birks. NEJM 2006;355:1873