Primary Angioplasty and Hemodynamic Support in Cardiogenic Shock

Department of Internal Medicine, College of Medicine, Yonsei University Hyuck Moon Kwon, M.D.

Epidemiology of Cardiogenic Shock

STEMI Non- STEMI Occurrence of shock Median time from enrollment to shock 4.2-7.2% (GUSTO) 9.6h

2.9% (PURSUIT) 76h Unstable angina 2.1% (PURSUIT) 94h Hasdai et al. JACC 2000;36:687

Definition of Cardiogenic Shock

SBP

< 90

mmHg for >30min-1 hr that is : • Unresponsive to fluid administration alone • Secondary to cardiac dysfunction, or • signs of end-organ hypoperfusion, or • CI<2.2L/min/m and PCWP>15-18mmHg.

• SBP increase to>90mmHg within 1 hr after administration of inotrophic agents • Death within 1 hr of hypotension but met other criteria for cardiogenic shock.

ACC clinical data standard JACC 2001;38:2127

ACC/AHA Guidelines (1999/2000) for PCI in Cardiogenic Shock

• Class I recommendation • Primary PTCA: within 36 hrs of an acute ST elevation / Q-wave or new LBBB who develop cardiogenic shock are < 75 years old, • Revascularization (PCI or CABG) within 18 hrs of onset of shock.

J Am Coll Cardiol 1999;34:`904

Predictors of Cardiogenic Shock after STEMI

• Patient’s age - most important • SBP • HR • Killip Class - Hasdai et al,Lancet 2000;356:749

Primary Angioplasty in CS

E mployed criteria ? GUSTO-1 Selection bias ? SHOCK vs SMASH Randomized controlled study?

Time of studies ? Overall mortality: 44% Successful PCI: 33% Unsuccessful PCI: 81%

GUSTO-I (Cardiogenic shock subgroup analysis)

•

Cardiogenic shock : 7.2% (among 41,021 pts)

•

Overall 30-day mortality : 55%

•

30-day mortality of CABG group : 29%

•

30-day mortality of PTCA group : 22%

•

Comparison of 1 yr mortality, PTCA vs no PTCA : the hazard ratio : 0.81(95% CI,0.71-0.94; p<0.005)

•

Limitations : not randomized study. Selection bias.

SHOCK trial : Randomized and controlled study

Acute Myocardial Infarction <= 36hr Shock <= 12hr Randomization Emergency Revascularization IABP/Pharmacological support Possible prior thrombolysis Emergency early PTCA(60%)/CABG(40%)<= 6 hrs Initial medical Stabilization IABP/Pharmacological support Thrombolysis unless absolute Contraindication (63%) Delayed revasc.(25%) >54hr • Primary end point : 30-day mortality • Secondary end point : 6 mo. mortality Hochman et al,NEJM 1999;341:625

SHOCK Trial : Mortality among Study Patients

Outcome and Subgroup ERV Medical Therapy percent(number in subgroup) Difference Relative risk P-value 30-day mortality Total Age<75yr Age>=75yr 6-mo. mortality Total Age<75yr Age>=75yr 46.7(152) 41.4(128) 75.0(24) 50.3(151) 44.9(127) 79.2(24) 56.0(150) 56.8(118) 53.1(32) 63.1(149) 65.0(117) 56.3(32) -9.3

-15.4

+21.9

-12.8

-20.1

+22.9

0.83

0.73

1.41

0.80

0.70

1.41

0.11

0.01

0.027

0.003

Hochman et al ,NEJM 1999;341:625

PCI in the SHOCK Trial Registry (93 97’, n=884) In-hospital mortality : 46.4% in PCI (n=276) vs 78.0% in medically (n=499) MI-PCI: Median 8.8hrs, Shock-PCI: 3.3hrs

PCI within 6 hrs of MI 40.2% PCI within 6-12 hrs of MI 50.9% PCI within 12-24 hrs of MI 60.5% PCI within 24hrs of MI 43.9%

Pts with PCI: younger, shock earlier, higher LVEF & CI Webb J et al, Am. Heart J.2001;141:964-71

Final TIMI flow grade after PCI and in-hospital mortality rates in SHOCK Registry patients with pump(Lt.or Rt.ventricular) failure. (P< 0.001).

100 85.7% 80 60 50.0% 40 33.3% 20 0 0 or 1(n=35) 2(n=24) 3(n=111) Final TIMI Flow Grade ( Webb J et al, Am. Heart J.2001;141:964-71)

Angiographic success and in-hospital mortality rates in SHOCK Registry patients with pump failure. Success is defined as residual stenosis<50% and final TIMI flow grade of 2 or 3(P< 0.001).

100 82.5% 80 60 36.1% 40 20 0 Unsuccessful(n=40) Successful(n=119) ( Webb J et al, Am. Heart J.2001;141:964-71)

Global Use of Revascularization for Pts. in Cardiogenic Shock: Global registry of Acute Coronary Events (GRACE, 99 00’, n=535)

Region Hospital mortality(%) ERV(%) Stent use GPIIbIIIa Inhibitor ANC Europe AB USA P value 58 65 79 39 < 0.0001

25 31 46 57 <0.0001

25 80 53 80 0.0019

5 15 9 26 0.0005

ANC: Australia/New Zealand/Canada, AB: Argentina/brazil •

The most powerful predictor of in–hospital survival : PCI with stenting (n=535, odds ratio, 5.8 ; 95% confidence interval, 3.3-10.4)

Dauerman et al, Am J cardiol 2001;88(suppl 5A)

Long-term Results after acute PCI in AMI with shock

12-months survival rate 47% SHOCK trial 60% Ajani et al. AJC 2001;87:633 80% Ammann et al. Int J of cardiology 2002;82:127 Early prediction - ERV with stenting & anti-PLT !!

Glycoprotein IIb/IIIa inhibitors

Beneficial effect of GP IIb/IIIa receptor blockers in patients undergoing primary PCI/ Stenting in CS: 1-month mortality (n=74) 19 vs 41% Antoniucci D et al. Am J Cardiol. 2001;88:5A In hospital mortality (n=323) 26.4 vs 34.4% Moscucci M et al. JACC. 2002;39:330A

Hemodynamic Support in Cardiogenic Shock

IABP in Cardiogenic Shock

• Diastolic inflation - Augmentation of DBP -Increases diastolic coronary arterial perfusion • Systolic Deflation - Afterload Reduction - Reduce LV wall stress - Decrease myocardial oxygen demand - Increase in cardiac output • Contraindicated in severe Aortic regurgitation !

IABP in Cardiogenic Shock complicating AMI

• IABP as an an adjunctive treatment to revascularization in GUSTO-I trial , a trend towards lower 30-day and 1 -year mortality rates.

(Anderson et al. JACC 1997;30:708-715) • SHOCK trial : IABP used in 86% • National Registry of MI-2 IABP in 7268/23180 (31%): Thrombolytic therapy with IABP :49 vs 67 % Primary angioplasty with IABP :47 vs 45 % (Barron et al,Am heart J 2001;141:933-939)

Conclusion

• Prevention is the best policy : identification of pre-shock state followed by preventing deterioration into cardiogenic shock.

• Strategy of ERV: PTCA/CABG accompanied with IABP support. for > 75yrs old,invasive strategy on case by case basis. • TIMI flow after PCI was strongly associated with in-hospital mortality rate.

Thrombolytic therapy

• The outcome of cardiogenic shock is closely linked to arteries the patency of the culprit coronary • Thrombolytic therapy has decreased the occurrence of shock among patients with persistent STEMI.

• The GUSTO-I : t-PA is more efficacious than streptokinase in preventing shock.

Thrombolysis in cardiogenic shock

• Results have been disappointing • Cause : ? limited efficacy of lytics in the setting of low perfusion pressure.

• GISSI-I Study Mortality of thrombolysis(streptokinase) group = 69.9% Mortality of. control group = 70.1% -David Hasdai et al,Lancet 2000;356:753