Shock cardiogeno
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(2) Primary myocardial dysfunction resulting in the inability of the heart to mantain an adeuqte cardiac output (CO) with subsequent compromising of metabolic requirements From: Civetta et al (eds) Critical Care.
(3) DEFINITION (1) • Decreased cardiac output • Evidence of tissue hypoxia • Adequate intravascular volume.
(4) DEFINITION (2) • Reduced CI ( < 2.2 l/min/ m2) • Sustained hypotension ( BP < 90 mmHG or drop > 30 mmHG for > 30 min) • WP > 15 mmHg.
(5) DEFINITION (3) • Poor tissue perfusion ( cold clammy skin, altered sensorium, oligo-anuria) • Hypotension • Jugular vein fillings, rales.
(6) CARDIOGENIC SHOCK Clinical Recognition • In the SHOCK trial: 64% of pts : • Hypotension; • Ineffective CO ( tachycardia, altered mentation, oliguria , cold periphery • Pulmonary congestion Menon V, et al. J Am Coll Cardiol 2000;36:1071–6..
(7) CARDIOGENIC SHOCK Clinical Recognition • In the SHOCK trial: 28% of pts : • • • •. Hypotension Hypoperfusion No pulmonary congestion ( silent lung) WP 21.5 + 6.7 mmHG Menon V, et al. J Am Coll Cardiol 2000;36:1071–6..
(8) GUSTO I study: 30 days mortality model importance of subjective signs • Altered sensorium. • Dying OR = 1.68. • Cold Clammy Skin. • Dying OR = 1.68. • Oliguria. • Dying OR = 2.25. Independently of objective hemodynamics From Hasdai D, et al. Cardiogenic shock complicating acute myocardial infarction: predictors of death. Am Heart J 1999;138:21–31..
(9) Causes (1) Systolic dysfunction (decreased contractility): ¾ Ischemia/Myocardial Infarction ¾ Global hypoxemia ¾ Myocarditis (viral, autoimmune, parasitic) ¾ Cardiomyopathies (hypertrophic, amyloid) ¾ Myocardial depressant drugs (eg, beta-blockers, calcium channel blockers, antiarrhythmics, propofol, anthracycline) ¾ Myocardial contusion ¾ Intrinsic Depression (eg, hypoxia, acidosis, hypocalcemia, hypophosphatemia).
(10) Causes (2) Diastolic dysfunction (increased myocardial stiffness) ¾ Ischemia ¾ Ventricular hypertrophy ¾ Restrictive cardiomyopathy ¾ Consequence of prolonged hypovolemic or septic shock ¾ Ventricular interdependence ¾ External compression by pericardial tamponade.
(11) Causes (3) Greatly increased afterload ¾ Aortic stenosis ¾ Hypertrophic cardiomyopathy ¾ Dynamic aortic outflow tract obstruction ¾ Coarctation of the aorta ¾ Malignant hypertension.
(12) Causes (4) Valvular or structural abnormality ¾ Mitral stenosis ¾ Endocarditis ¾ Mitral aortic regurgitation ¾ Obstruction due to atrial myxoma or thrombus ¾ Papillary muscle dysfunction or rupture ¾ Ruptured septum or free wall ¾ Arrhythmias.
(13) Main Cause ¾ Miocardial Infarction (MI) Cardiogenic Shock Complicates 4.2-7.2 % of the MIs Leading cause of death (mortality rate ≈ 50%) Usually develops for losses of tissue mass greater than 40 %.
(14) (N Engl J Med 1999;340:1162-8.).
(15) Ann Intern Med. 1999;131:47-59..
(16) Loss of myocardial contractility ↓ CO. ↓ Blood pressure ↑ Adrenergic response. ↑ Inotropism. ↑ HR. ↑ Myocardial VO2. ↑ Arterial tone. ↑ Venous tone. ↑ Afterload. ↑ Preload. ↓ Myocardial perfusion. Worsening in myocardial ischemia. ↑ Ventricular ∅.
(17) Preload does not help… Cardiac Output (l/min). 10. Normal. 8. 6. 4. Depressed contractility. 2. 5. 10. 15. 20. 25. Wedge Pressure (mmHg). 30. 35.
(18) In the lungs ↑ Preload. ↓ Diastolic Function. ↑ Atrial pressure. ↓ Splancnic perfusion. H2O retention. Pulmonary vasculature congestion. Worsening of hypoxaemia.
(19)
(20) Challenging the paradigm • • • •. LV EF approx 30% Average SVR not elevated ( wide range) SIRS obviuos Survivors class I CHF status. From the SHOCK study.
(21) Influence of inflammatory response. From: Circulation 2003; 107: 2998-3002.
(22) Role of systemic inflammation • A substantial number of patients die with a normalized CI in absence of obvious infection (22.5%) • Release of mediators secundary to gut hypoperfusion? Chest 2003, 124:1885-1891.
(23) Left ventricle always guilty? SHOCK Registry: • In 49 of 993 patients (5%) the shock was caused by right heart infarction • Mortality not different in the right vs left ventricular shock J Am Coll Cardiol 2003, 341:1273-79.
(24) Causes of RV failure ¾ Right heart infarction ¾ Acute Cor Pulmonale Massive Pulmonary embolism Acute Respiratory Distress Syndrome.
(25) The RV failure Loss of myocardial contractility ↓ CO. ↓ PAP. ↑ RV Volume ↑ RV Pressure Tricuspid insufficency. ↓ LV preload. ↓ WP !. Venous district and splanchnic congestion. Hypoxaemia Int Care Med 2004, 30:185-96.
(26) Hemodynamic patterns during shock BP HR CO CVP WP Hypovolemic shock. ↓. ↑. ↓. ↓. ↓. Left Ventricular MI. ↓. ↑. ↓. ↓ Or Nl. ↑. Right Ventricular MI. ↓. ↑. ↓. ↑. ↓ Or Nl. Pericardial Tamponade. ↓. ↑. ↓. ↑ Equalized. Massive Pumonary Embolism. ↓. ↑. ↓. ↑ Or Nl ↓ Or Nl. ↓. ↑. ↑. ↓ Or Nl ↓ Or Nl. Cardiogenic shock. Extracardiac Obstructive. Septic/Anaphilactic shock.
(27) CARDIOGENIC SHOCK Therapy • Immediate resuscitation • Early definition of coronary anatomy • Early revascularization.
(28) CARDIOGENIC SHOCK Immediate resuscitation • Pressure: dopamine noradrenaline dobutamine • Monitor ECG, defibrillators and drugs available ( 33% of SHOCK trial had CPR, VT, or VF) • Oxygen, CPAP, CPPV • Aspirin, heparin • Fibrinolitics if PCI > 90-120 min • IABP.
(29) CARDIOGENIC SHOCK Early definition of coronary anatomy. Circulation 2003: 107: 2998.
(30) Circulation 2003: 107: 2998. CARDIOGENIC SHOCK Early revascularization.
(31) Intraaortic Balloon Counterpulsation. BMJ 2003;326:1450-1452.
(32) Intraaortic Balloon Counterpulsation. BMJ 2003;326:1450-1452.
(33) Intraaortic Balloon Counterpulsation. BMJ 2003;326:1450-1452.
(34) Mortality rate after MI. Better drugs ? (N Engl J Med 1999;340:1162-8.).
(35) Patients with cardiogenic shock complicating MI. Medical Therapy. Revasculatization. - Thrombolitic therapy - Intraaortic balloon counterpulsation. - Angioplasty/Bypass surgery - Intraaortic balloon counterpulsation.
(36) Conclusions At 30 days there was no significant overall benefit of early revascularization for patients with myocardial infarction who had cardiogenic shock due to left ventricular dysfunction. However, early revascularization resulted in lower mortality from all causes at six months..
(37) The current strategy Cardiogenic shock : commonest cause of death in AMI. -thrombolysis can be attempted with inotropic support or augmentation of blood pressure with the intra-aortic balloon pump - greatest mortality benefit seen after urgent coronary angiography and revascularisation BMJ 2003;326:1450-1452.
(38) CARDIOGENIC SHOCK • • • •. VAD LVAD ECMO Et al…….
(39) Rossi F et al J.Thorac Cardiovasc Surg 100:914:1990.
(40) Healing the heart with ventricular assist devices therapy • Reversal of left ventricular remodeling: reduction of LV size, improved contractility, regression of myocyte hypertrophy. • Molecular remodeling: apoptosis regulation, improved calcium exchange.
(41)
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