How to do Primary Angioplasty
- Patients with Cardiogenic Shock
Advanced Cardiovascular Intervention
2011
Dan Blackman
Leeds General Infirmary
MY CONFLICTS
OF INTEREST ARE:
Research Grants
Medicines Company
Advisory Board
Medicines Company
Lilly
Causes of Cardiogenic Shock
Tamponade/rupture
1.7%
Isolated RV Shock
3.4%
Other
7.5%
VSD
4.6%
Acute Severe MR
8.3%
Shock Registry
JACC 2000 35:1063
Predominant LV Failure
74.5%
Survival from mechanical causes
100%
No Surgery
Surgery
Percutaneous closure
94%
90%
In-hospital Mortality (%)
80%
71%
70%
60%
50%
47%
39%
40%
28%
30%
20%
10%
0%
VSD
Shock Registry JACC 2000;36:1104 & 36: 1110
GUSTO 1 Circulation 2000;101:27
Holzer R CCI 2004;61:196
Acute Severe MR
Emergency revascularisation - SHOCK Trial
p=0.02
90%
p=0.03
80%
Mortality (%)
70%
p=0.03
p=0.11
66%
63%
56%
60%
50%
80%
47%
50%
67%
53%
40%
30%
20%
10%
0%
30 days
(n=302)
6 months
(n=301)
12 months
(n=299)
6 years
85% of survivors NYHA Class I/II at 12 months
Hochman JAMA 2000;285:190
ERV
IMS
Single or Multi-vessel PCI?
• 81% of PCI patients multi-vessel disease
• 85% PCI IRA only; 23% complete revascularisation
90%
1-year mortality (%)
80%
80%
70%
60%
p<0.01
p=NS
p=NS
50%
50%
45%
54%
46%
39%
40%
30%
20%
10%
0%
MV PCI SV PCI
Complete Partial
Shock Trial
MV PCI SV PCI
Shock Registry
Role of CABG
p=NS
60%
53%
1-year mortality (%)
50%
48%
46%
40%
PCI
CABG
30%
24%
20%
10%
0%
SHOCK Trial
n=81
n=47
SHOCK Registry
n=276
n=109
• SHOCK Trial CABG vs PCI baseline characteristics
– LMS Disease 41% vs 13% p=0.051
– 3VD
80% vs 60% p=0.18
– Diabetes
49% vs 27% p=0.11
AHA/ACC Guidelines for Revascularisation
PCI Strategy in Cardiogenic Shock
• Stabilise the patient first, open the vessel second
•
•
•
•
Up-front IABP
Central venous access
Inotropic/Pressor support as required
Anaesthetic support in the cath lab
SOAP II – Comparison of Dopamine and
Norepinephrine in Shock
• 1679 patient RCT in shock
• 280 patients cardiogenic
• Increased arrythmia with
dopamine (AF/VT/VF)
• Significantly lower
mortality with
norepinephrine in CS
• Vasoconstriction (by SVR) is often absent*
• Patients with vasoconstriction have better outcome*
De Backer, NEJM, 2010;362:779.
Cardiogenic
Shock
Systolic BP
>100mmHg
Systolic BP
70-100mmHg
NO Shock
Systolic BP
70-100mmHg
With Shock
Systolic BP
<70mmHg
With Shock
Nitroglycerin 1020mcg/min
Dobutamine
2-20mcg/kg/min
Dopamine 515mcg/kg/min
Norepinephrine
130mcg/kg/min
Antmen, JACC, 2004;44:671
Abciximab in Cardiogenic Shock
70%
PCI
PCI +Abciximab
62%
30 day Mortality (%)
60%
50%
44%
44%
40%
39%
36%
30%
26%
22%
22%
20%
21%
9%
10%
0%
Antoniucci
(stent)
n=77
Chan Stent
n=41
Chan PTCA
n=55
Giri
(50% stent)
n=113
ADMIRAL (stent)
n=25
PRAGUE-7 study
• 80 patient RCT
• Up-front (n=40) vs provisional (n=40) abciximab in
PPCI for cardiogenic shock
120%
Event rate (%)
100%
Up-front
Provisonal
100%
P=NS for all
80%
60%
40%
35%
37%
42%
32%
27%
20%
10%
5%
0%
Abciximab given
Mortality
MACE
TIMI Major Bleeding
Intra-aortic balloon pump counterpulsation
TT only
TT + IABP
80
69
70
68
63
59
Mortality (%)
60
50
47
49
45
43
40
34
30
23
20
10
0
Shock Registry
(n=292)
NRMI Registry
(n=23,180)
TACTICS
GUSTO I & III
Kovack
(n=46)
IABP in Cardiogenic Shock Primary PCI
Retrospective analysis of 23,180 patients from NRMI database
7268 treated by IABP
80
In-hospital Mortality (%)
70
67
60
49
50
46
42
40
30
20
10
0
Thrombolysis only
Thrombolysis + IABP
Primary PCI only
Primary PCI + IABP
Timing of IABP in Cardiogenic Shock
Primary PCI
40%
35%
35%
IABP pre (n=62)
IABP post/none (n=57)
30%
30%
Event rate (%)
35%
25%
20%
15%
15%
15%
13%
10%
5%
0%
CPR
VF/VT arrest
Any event
• Single centre registry Primary PCI for shock
Brodie AJC 1999;84:18
Tandem Heart pLVAD
• Left atrial-to-femoral arterial LVAD
• Low speed centrifugal continuous
flow pump
• 21F venous transeptal cannula
• 17F arterial cannula
• Maximum flow 4L/minute
• Expensive +++
Tandem Heart Outcome Data
p=NS
50%
45%
45%
42%
40%
30 day mortality (%)
Tandem Heart
IABP
47%
36%
35%
30%
25%
20%
15%
10%
5%
0%
Thiele (n=41)
Burkhoff (n=33)
Improved haemodynamic parameters
Increase in bleeding, limb ischaemia, and sepsis
Thiele EHJ 2005;26:1276. Burkhoff AHJ 2006;152:e1
Impella
•
•
•
•
Axial flow pump
Much simpler to use
Increases cardiac output & unloads LV
LP 2.5
– 12 F percutaneous approach; Maximum 2.5 L flow
• LP 5.0
– 21 F surgical cutdown; Maximum 5L flow
• Expensive ++
Blood Inlet
Blood outlet
Motor
Pressure Lumen
Impella outcome data
• ISAR-SHOCK
–
–
–
–
26 patient RCT Impella vs IABP
 Cardiac Index,  MAP (by 10mmHg) vs IABP
Complications ≤ IABP
No difference in mortality
• PROTECT-II
–
–
–
–
654 patients RCT IABP vs Impella in high-risk PCI
Stopped after n= 305 due to futility
Primary EP composite of 10 MAEs
Incidence 38% Impella vs 43% IABP
How to treat STEMI + Cardiogenic Shock
• Emergency angiography and revascularisation
• On-table echo to rule out mechanical defects
• Stabilise the patient in the lab before revascularisation
– IABP
– Central venous access
– Pressors if required – Norepinephrine (dopamine)
– Anaesthetic support
• Consider calling the surgeon for true surgical disease
• PCI culprit artery. Consider other vessels if shock persists. Staged
PCI or CABG if patient stabilises
• Consider percutaneous VAD if shock persists with IABP + effective
revascularisation
ESC Guidelines for Cardiogenic Shock
Revascularisation: SHOCK trial
STEMI complicated by shock due to LV failure n= 302
Hypotension (SBP<90mmHg), End organ hypoperfusion,
CI<2.2, PCWP>15mmHg
Randomised within 36 hours of index event
Emergency Revascularisation (152)
PCI or CABG within 6hr
IABP recommended
PCI = 81 and CABG =
47
Medical (150)
IABP
Revasc at 54 hours
Primary endpoint:
30 day mortality
Secondary endpoint: 6 and 12 month mortality
Late follow-up
NYHA I-II
NYHA III-IV
Death
Sleeper, JACC, 2005; 46:266.
Heart Attack: The Challlenge, Manchester 2010
Shock: Incidence, Diagnosis, Treatment,
Outcome
Emergency revascularisation in the Elderly
- SHOCK Trial
80%
30-day Mortality (%)
70%
60%
ERV
IMS
75%
p=0.01
p=0.01
57%
53%
50%
41%
40%
30%
20%
10%
0%
<75 years (n=246)
>75 years (n=56)
• >75 years ERV vs IMS baseline characteristics
– LVEF
28% vs 36% p=0.051
– Anterior MI 63% vs 41% p=0.18
– Female
54% vs 31% p=0.11
Elderly - SHOCK & other registry data
ERV
IMS
90%
81%
30-day Mortality (%)
80%
70%
60%
50%
48%
47%
46%
40%
30%
20%
10%
0%
SHOCK Registry
n=44
n=233
Mayo Clinic
n=61
Northern New
England
n=74
Why worry about Cardiogenic Shock?
Cardiogenic shock complicates 6-8% of STEMI*
Mortality is 60.1%**
It is the leading cause of death from STEMI
* GUSTO, NRMI, GRACE
** Shock registry JACC 2000
ESC Guidelines for Revascularisation
• Complete revascularisation has been
recommended with PCI in all critically stenosed
large epicardial coronary arteries
Right Ventricular Infarction (3%)
• Shock with clear lungs
• Elevated JVP
• ECG and echo
• Maintain preload
• Reduce RV afterload
• Maintain AV synchrony
Mortality by PCI outcomes
100
100
85
90
80
70
55
60
50
40
38
39
30
20
10
0
3 1 2 1-0
TIMI FLOW
Webb, JACC 2003;42:1380.
2
SuccUnsucc
PCI
Percutaneous left ventricular assist devices
• Even with revascularisation and IABP support mortality from
cardiogenic shock post STEMI remains ≥50%
• Recovery of myocardial performance following successful
revascularisation may take several days. During this time
many patients succumb to low cardiac output
• Efficacy of IABP is limited by the lack of active cardiac
support, requirement for a certain level of LV function, and
the need for accurate synchronisation with cardiac cycle
• Patients with severely impaired LV function and/or persistent
tachyarrhythmias derive little benefit from IABP
Management Principles
• Diagnose & treat causes other than LV failure
• Support cardiac output and organ perfusion
– Inotropes / pressors
– Mechanical support
• Early Revascularisation
• PCI/CABG
Inotropes and Vasopressors
Agent
Dose
μg/min
α
β
Arrhythmia
vasoconstrict
Inotropy/vasodilate
Epinephrine
2-10
++
+++
+++
Norepinephrine
0.5-30
+++
++
++
5-10
++
++
++
10-20
+++
+++
+++
Dobutamine
2-20
+
+++
++
Isoproterenol
2-10
0
+++
+++
Dopamine
• Vasoconstriction (by SVR) is often absent*
• Patients with vasoconstriction have better outcome*
* SHOCK Data
PCI + staged CABG
• Chiu et al
• Single centre retrospective registry study
• PCI only vs PCI + staged CABG for cardiogenic
shock with multivessel disease
• Propensity matched n=44 in each group
• 1.3 vessels revascularised by PCI; 2.6 by CABG
• 30-day mortality 20.5% PCI + CABG vs 40.9%
PCI only