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Management

Cardiogenic Shock complicating AMI


Bagus Ari Pradnyana
Department Cardiology & Vascular Medicine
Faculty of Medicine Udayana University

CARDIOGENIC SHOCK
Cardiogenic shock is a physiologic state in which
inadequate tissue perfusion results from cardiac
dysfunction, most commonly following acute myocardial
infarction (MI).
The clinical definition of cardiogenic shock is
cardiac output (CO) and evidence of tissue hypoxia in the
presence of adequate intravascular volume.

Hemodynamic criteria for cardiogenic shock are


sustained hypotension (systolic blood pressure <90 mm Hg for
at least 30 min) and
a reduced cardiac index (<2.2 L/min/m2) in the presence of
elevated pulmonary capillary occlusion pressure (>15 mm Hg).

Cardiogenic Shock, intracardiac


Myocardial Injury or Obstruction to Flow
Arrythymias
valvular lesions
AMI
Severe CHF
VSD
Hypertrophic Cardiomyopathy

Pathophysiology Myocardial Infarction

Cardiogenic shock complicating AMI


Incidence 7-25%
Hospital Mortality
70s 90%
20s 50%

Indonesia ??

Mortality : SHOCK registry

JACC,2000 36(3): 1063

ACC/AHA Guidelines Management STEMI 2004

Management

PCI for Cardiogenic Shock


Cardiogenic Shock
Early Shock, Diagnosed on
Hospital Presentation

Delayed Onset Shock


Echocardiogram to Rule Out
Mechanical Defects

Fibrinolytic therapy if all of the


following are present:
1. Greater than 90 minutes to PCI
2. Less than 3 hours post STEMI
onset
3. No contraindications
Arrange prompt transfer to invasive
procedure-capable center

Arrange rapid transfer to invasive


procedure-capable center

IABP
Cardiac Catheterization and Coronary
Angiography

1-2 vessel CAD

Moderate 3-vessel CAD

PCI IRA

PCI IRA

Staged Multivessel
PCI

Severe 3-vessel CAD

Left main CAD

Immediate CABG

Staged CABG

Cannot be
performed

PCI After Fibrinolysis

I IIa IIb III

In patients whose anatomy is suitable, PCI should be


performed for the following:
Objective evidence of recurrent MI

I IIa IIb III

Moderate or severe spontaneous/provocable


myocardial ischemia during recovery from STEMI
I IIa IIb III

Cardiogenic shock or hemodynamic instability.

Primary PCI for STEMI:


Specific Considerations
It is reasonable to perform primary PCI for
patients with onset of symptoms within the prior
12 to 24 hours and 1 or more of the following:
I IIa IIb III

a. Severe CHF
b. Hemodynamic or electrical instability
c. Persistent ischemic symptoms.

Rescue PCI
I IIa IIb III

Rescue PCI should be performed in patients less


than 75 years old with ST elevation or LBBB who
develop shock within 36 hours of MI and are
suitable for revascularization that can be
performed within 18 hours of shock.

I IIa IIb III

Rescue PCI should be performed in patients with


severe CHF and/or pulmonary edema (Killip class
3) and onset of symptoms within 12 hours.

Rescue PCI
I IIa IIb III

I IIa IIb III

Rescue PCI is reasonable for selected patients 75


years or older with ST elevation or LBBB or who
develop shock within 36 hours of MI and are suitable
for revascularization that can be performed within 18
hours of shock.
It is reasonable to perform rescue PCI for patients
with one or more of the following:
a. Hemodynamic or electrical instability
b. Persistent ischemic symptoms.

PCI for Cardiogenic Shock


I IIa IIb III

I IIa IIb III

Primary PCI is recommended for patients less than


75 years with ST elevation or LBBB or who develop
shock within 36 hours of MI and are suitable for
revascularization that can be performed within 18
hours of shock.
Primary PCI is reasonable for selected patients
75 years or older with ST elevation or LBBB or
who develop shock within 36 hours of MI and
are suitable for revascularization that can be
performed within 18 hours of shock.

Emergency Management of Complicated STEMI


Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema
Most likely major underlying disturbance?

First line of action


Second line of action
Third line of action

Administer
Furosemide IV 0.5 to 1.0 mg/kg
Morphine IV 2 to 4 mg
Oxygen/intubation as needed
Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP
greater than 100 mm Hg
Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to
100 mm Hg and signs/symptoms of shock present
Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70
to 100 mm Hg and no signs/symptoms of shock

Check Blood Pressure


Systolic BP
Greater than 100 mm Hg
and not less than 30 mm Hg
below baseline

Low Output Cardiogenic Shock

Hypovolemia

Acute Pulmonary Edema

Administer
Fluids
Blood transfusions
Cause-specific
interventions
Consider vasopressors

Arrhythmia

Bradycardia

Check Blood Pressure

Tachycardia

See Section 7.7


in the ACC/AHA Guidelines for
Patients With ST-Elevation
Myocardial Infarction

Systolic BP
Greater than 100 mm Hg

Systolic BP
70 to 100 mm Hg
NO signs/symptoms
of shock

Systolic BP
70 to 100 mm Hg
Signs/symptoms
of shock

Systolic BP
less than 70 mm Hg
Signs/symptoms of shock

Nitroglycerin
10 to 20 mcg/min IV

Dobutamine
2 to 20
mcg/kg per
minute IV

Dopamine
5 to 15
mcg/kg per
minute IV

Norepinephrine
0.5 to 30 mcg/min IV

ACE Inhibitors
Short-acting agent such as
captopril (1 to 6.25 mg)
Further diagnostic/therapeutic considerations (should be considered in
nonhypovolemic shock)
Diagnostic
Therapeutic
Pulmonary artery catheter
Intra-aortic balloon pump
Echocardiography
Reperfusion/revascularization
Angiography for MI/ischemia
Additional diagnostic studies

Circulation 2000;102(suppl I):I-172-I-216.

Invasive monitoring
BP monitoring
highly recommended

Right Heart
catheterization
Supported by
GUSTO-1
SHOCK registry

Iakobishvili, Z, Med Clin N Am 91(2007) : 713-27

Swan-Ganz Catheter

Morphine and its analogues


In patient present with restlessness and
dyspnoea
Morphine induces
Venodilatalion
Mild arterial dilatation
Reduce heart rate
Dose : 3 mg IV bolus
Repeated if required

ESC guidelines Acute Heart Failure, 2005

Diuretics
For achieving optimal volume status eliminate or
minimize congestion
Progressive desaturation and pulmonary congestion
CS need optimization of LV filling pressure

to ensure maximal performance on starling force


Might difficult : RHC, hourly monitored urine output

Inotropes:
Dopamine, Dobutamine, Norephenephrine Milrinone
No large scale controlled study comparing
combination inotropes in cardiogenic shock
An important pharmacologic defense in the early
stage shock to maintain MAP 60 mmhg
Clinical course, symptom and prognosis may
depend on haemodynamics parameter
Improvement of haemodynamics may become a goal
of treatment
Enhance CO through the use of inotropic agents
Increase SVR through the use of vasopressors
ESC, Acute Heart Failure, 2005
Iakobishvili, Z, Med Clin N Am 91(2007) : 713-27

Role of Inotropes
cardiogenic shock
diuretic/ACE inhibitor refractory heart failure
decompensations
a short-term bridge to definitive treatment, such
as revascularization or cardiac transplantation,
is potentially appropriate

Felker GM. Am Heart J. 2001;142:393401.

Arrhythmias During Acute Phase of STEMI:


Pump Failure / Excess Sympathetic Tone
Arrhythmia

Treatment

Sinus Tach

Treat cause; beta blocker

Afib / Flutter

Treat cause; slow ventricular rate; DC shock


digoxin 0.125-0.25 mg IV or amiodarone

PSVT
Vagal maneuvers; beta blocker,
verapamil / diltiazem; DC shock

ESC, Acute Heart Failure, 2005


ACC/AHA Guidelines Management STEMI 2004

Arrhythmias During Acute Phase of STEMI:


Bradyarrhythmias
Arrhythmia

Treatment

Sinus Brady

Treat if hemodynamic compromise;


atropine / pacing

Junctional

Treat if hemodynamic compromise;


atropine / pacing

ACC/AHA Guidelines Management STEMI 2004

Summary
All resources must be used in
Mechanical complication must be identified
May need different initial pharmacologic approached

In the early stage shock it is essential to


maintain MAP 60 mmhg with inotropic & IABP
Revascularization is indicated for < 75 yo. within
18 hours of shock.
PCI/CABG are preferred

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