Transcript PowerPoint-presentation

Cardiogenic shock in
myocardial infarction
Lars Wiklund, MD, PhD
Dept of Cardiothoracic Surgery
Cardiogenic shock in MI
Serious complication
7-8 % of ST-elevation in ACS
High mortality
Percentage of patients treated with PCI in
cardiogenic shock i Sweden (SCAARregistry)
Andel
(%)
10
9
8
7
6
5
4
3
2
1
2007
2006
2005
2004
2003
2002
2001
2000
1999
0
Figur 46.2. Andel cardiogen chock bland de PC I-behandlade STEMI-patienterna, 1999 - 2007.
(endast diagnostik undantaget)
Cardiogenic shock in MI
Numeros retrospective studies
SHOCK trial 1999
Should We Emergency Revascularize Occluded
Coronaries for Cardiogenic Shock (SHOCK-trial)
Hochman et al NEJM 1999 341:625-634
Outcome of patients aged ≥75 years in the SHOCK) trial
Dzavik et al Am Heart J 2005;149:1128-34
One-Year Survival Following Early Revascularization for
Cardiogenic Shock
Hochman et al JAMA. 2001;285:190-192.
Kaplan-Meier Long-term Survival of All Patients and
Those Discharged Alive Following Hospitalization
Hochman et al JAMA 2006;295:2511-2515
PCI vs CABG in the shock-trail
White et al Circulation. 2005;112:1992-2001
Changes in the logistics since SHOCK trial
Antman, E. M. et al. Circulation 2008;117:296-329
Copyright ©2008 American Heart Association
Guidelines (European Society of Cardiology)
PCI
1 choice of treatment
CABG
failed PCI
refractory sympoms after PCI
not amenable for PCI
mechanical complication (VSD, MI)
Primary CABG in STEMI-patients in
Sweden (SCAAR-registry)
Andel
(%)
11
10
9
8
7
6
5
4
3
2
1
2007
2006
2005
2004
2003
2002
2001
2000
0
Figur 43. Andel STEMI-patienter som får C ABG som primärt beslut vid angiografi, 2000-2007.
Nomogram to predict postoperative death in patients
with cardiogenic shock undergoing CABG
Mehta et al Circulation 2008;117:876-885
Risk score and operative mortality in patients with
cardiogenic shock undergoing cardiac surgery
Mehta et al Circulation 2008;117:876-885
Does current treatment of cardiogenic shock complicating
the acute coronary syndromes comply with guidelines?
Cardiogenic shock absent
(n=9587)
<75 y (n = 7166)
≥75 y (n = 2406)
Coronary angiography
59.7%
34.4%
PCI
36.0%*
CABG
IABP
Total
Cardiogenic shock present
(n=549)
<75 y (n = 346)
≥75 y (n = 199)
53.3%
64.2%
32.7%
52.4%
19.4%
31.8%†
52.2%*
21.6%
40.8%†
5.0%
2.8%
4.5%
5.2%
3.0%
4.4%
0.9%*
0.6%‡
0.8%†
21.7%*
11.1%‡
17.7%†
.
Iakobishvili et al Am Heart J, 2005;149:98-103
Cardiogenic
Shock
Cardiogenic
Shock
Absent (n = 9587)
Present (n = 549)
ST elevation ACS
2.7%
50.3%
<.001
Non-ST elevation ACS
1.2%
53.2%
<.001
Undetermined ECG
5.0%
60.0%
<.001
Q wave MI
3.5%
54.2%
<.001
Non-Q-wave MI
2.8%
53.6%
<.001
Unstable angina
0.6%
64.6%
<.001
Total mortality
2.0%
52.1%
<.001
Initial diagnosis
Final diagnosis
IABP and PCI
Is there a benefit of intra-aortic
ballon pump theraphy in STelevation MI?
Meta-analysis
Eur Heart J 2009;30:459-68
Eur Heart J 2009;30:459-68
How to improve survival?
•Secure circulation
•Mechanical assist devices
Extra Corporeal Membrane Oxygenation
(ECMO)
ECMO Cardiogenic Shock
(Stockholm and Göteborg)
Liden et al Scand Cardiovasc J 2008;16:1-7.
ECMO Cardiogenic Shock
(Stockholm and Göteborg)
Liden et al Scand Cardiovasc J 2008:16:1-7.
Implant Dates: June 23, 2006 – March 31, 2009
Patient Profile at Implant
Level 3 (Stable but Inotrope
Dependent), n=172, deaths=20
Level 4 (Recurrent Advanced
HF), n=116, deaths=16
100
90
80
% Survival
70
60
50
Level 1 (Critical Cardiogenic
Shock), n=481, deaths=121
40
Level 2 (Progressive Decline),
n=514, deaths=102
30
20
10
0
0
Levels 5,6,7: All Others, n=78,
deaths=16
p (overall) < .0001
Event: Death (censored at transplant or recovery)
3
6
9
12
15
18
Months after Device Implant
21
24
LVAD in patients with MI
Outcome
Group I (n = 49)
Group II (n = 61)
p
Transplanted
38 (78%)
37 (61%)
0.07
Pretransplant LVAD support (days)
56 ± 54
65 ± 79
0.55
Posttransplant length of stay (days)
24 ± 15
35 ± 33
0.11
Total hospital length of stay (days)
51 ± 50
54 ± 70
0.85
30 day transplant mortality
4 (8%)
1 (2%)
0.11
In-hospital mortality
16 (33%)
25 (41%)
0.91
Leshnover et al 2005 Ann Thorac Surg;81:1365-71
Thank you