5.2 Dr.yusuf Assegaf SpJP - Syok Kardiogenik

8/11/2019 5.2 Dr.yusuf Assegaf SpJP - Syok Kardiogenik

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CARDIOGENIC SHOCK

Department of Cardiology and Vascular Medicine

Airlangga School of Medicine - Dr. Soetomo Teaching Hospital Surabaya

Mochamad Yusuf, MD FIHARika Yenni P, MD

Rommy, MD


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BACKGROUND


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BACKGROUND

Some facts:

The incidence remained stable

over the past 3 decades

In-hospital mortality: 60%

(SHOCK Trial Registry) and

50-80% (older series)

Mostly after reaching hospital


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Brain: Altered mental status

CIRCULATORY SHOCK

Kidney: Oliguria

Skin: Mottled, clammy

Tachycardia

Blood lactate !

Arterial hypotension

Absent

Chronic

hypotension?

Syncope (if

transient)

Vincent JL, 2013


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CIRCULATORY SHOCK

Normal chamber & usuallypreserved contractility

Distributive Shock Cardiogenic Shock

Large ventricle & poorcontractility

In tamponade: pericardial effusion,

small RV & LV, dilated IVC; inpulmonary embolism or

pneumothorax: dilated RV, small LV

Obstructive Shock

Small chamber & normal/

high contractility

Hypovolemic Shock


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Brain: Altered mental status

Kidney: Oliguria

Skin: Mottled, clammy

Tachycardia

Blood lactate !

CIRCULATORY SHOCK

Arterial hypotension

Present

Circulatory

shock

Est. CO or SVO2

Normalor high

Low

LowCVP

HighCVP

Distributiveshock

Hypovolemicshock

Cardiogenic& obstructive

shock

Shock: clinical expression of circulatory failure

that results in inadequate cellular oxygenutilization. Vincent JL, 2013


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Cardiogenic Shock

Large ventricle & poorcontractility

CARDIOGENIC SHOCK

Persistent hypotension and tissue hypoperfusion

due to cardiac dysfunction with adequate

intravascular volumeand LV filling pressure.

Hypotension, tachycardia, oliguria, cool extremities & altered mental status

Sustained hypotension: SBP < 90 mm Hg for 30 mins

Low cardiac index: 15 mmHg

Clinical Sign

Hemodynamic Finding


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ETIOLOGY

LV Failure78%

MR7%

VSR4%

RV infarct3%

Tamponade / Free wall rupture1%

Others7%

Causes of Cardiogenic shock in AMI

(SHOCK trial)

Topalian, 2008

Cardiac: Acute myocardial infarction

End-stage cardiomyopathy

Myocarditis

LVOT obstruction (AS / HOCM)

Obstruction to LV filling (MS / LAmyxoma)

Acute mitral / aortic regurgitation(chordal rupture)

TamponadeNon Cardiac:

Severe pulmonary arterialhypertension

Acute severe pulmonary embolism


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PATHOPHYSIOLOGY

Acute MI

LVEDP !Lung Edema

Hypoxia

Cardiac Output "Stroke Volume "

Hypotension

Coronary

perfusion "Peripheral

perfusion "

VasoconstrictionFluid retention

SVR "Pro-inflammationCathecolamin sensitivity"Contractility "

NO !Peroxynitrite !

IL-6 !TNF-#!

eNOS iNOS

Inotropes /

Vasopressors x

Mechanical supports:IABP/LVADx

Reperfusions:PCI/CABG

x


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MYOCARDIAL ISCHEMIA

Cell

death

No return

of function

Reperfusion

Significantresidual stenosis

Myocardial

stunning

Both stunning& hibernation

Myocardial

hibernating

Innotropic

support

Relief ofischemia

Return of

function

Hollenberg, 1999


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ESC ALGORITHM


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MECHANICAL SUPPORT


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IATROGENIC SHOCK

Coronary occlusion

LV compliance " PCWP ! CO "or unchanged

Redistribution of

intravascular volumeto lung

Pulmonary edema

Lower CO

Hypotension

Cardiogenic shock

RV infarction

RV RVEDP !(>15)

CVP !

Shift of interventricularseptum toward LV

Impaired LV filling &systolic function due tochanges in LV geometry

Low SV Compensatory

tachycardia

DiureticPreload "

Intravascular volume "

SVR "

$blocker

Reynolds, 2008

ACEiNitrate


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ASSESSMENT OF CARDIOGENIC SHOCK

Systemic hypotension(SBP


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ASSESSMENT OF CARDIOGENIC SHOCK

Laboratory

Elevated lactate level and decreased serum bicarbonate Increasing blood urea nitrogen and creatinine

Electrocardiographic

New or recurrent electrocardiographic evidence of ischemia or infarction

Chest X-RayNew or worsening pulmonary congestion

Echocardiographic

Hemodynamic assessment/monitoring (left/right ventricular systolicfunction, decreased stroke volume, cardiac output/index, diastolic function,PCWP, PA pressure, SVR, PVR, IVC)

Contractility Mechanical abnormalities (ventricular septal/free wall rupture, pericardial

fluid with tamponade)

Valvular dysfunction (severe mitral regurgitation)


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INITIAL MANAGEMENT

E

M

0min

R

G

E

N

5

min IC

C

Y

R

15min

CU

O

M 60min

EARLY TRIAGE & MONITORING

INITIAL RESUSCITATION

Age: 6574, %75 Heart rate >100 beats/ min Systolic BP20/min), (>30/min) Killip class II-IV

Clinical symptoms of tissue hypoperfusion/hypoxia

Arterial line and CVC Standard transthoracic echocardiogram (assess LV&RV

function and mechanical complications of MI)

Early coronary angiography in myocardial interventioncenter when signs and/or symptoms of ongoing myocardial

ischemia (e.g. STEMI)


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INITIAL MANAGEMENT

Start high flow O2

Establish i.v. access

CORRECT: hypoglycemia & hypocalcemia

TREAT: sustaned arrhythmias: brady or tachy, Isotonic saline-fluid challenge of 20-30

ml/kg/BW over a 30 until CVP 8-12 mmHg or perfusion improves (max500 ml)

CONSIDER: NIV mechanical ventilation for comfort (fatigue, distress) or to correct

acidosis/ hypoxemia

INOTROPIC SUPPORT(dobutamine and/or vasopressor support)

E

M

0min

R

G

E

N

5

min IC

C

Y

R

15min

CU

O

M 60min

EARLY TRIAGE & MONITORING

INITIAL RESUSCITATION


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INITIAL MANAGEMENT

Central venous saturation

(ScvO2) %70% (provided SpO2

%93% and Hb level %9 g/dL)

In persistent drug-resistant cardiogenic shock,

consider mechanical circulatory support

MAP %60 mmHg

PCWP &18 mmHg or below

CVP 8-12 mmHg

Urinary ouput %0,5 ml/hr/kgBW

Arterial pH of 7.3-7.5


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Take Home Messages

Cardiogenic shock is the most common cause ofdeath in patients hospitalized with acute myocardial

infarction and is associated with a poor prognosis.

Appropriate treatmentis based on a good

understanding of the underlying pathophysiological

mechanisms.

Cardiogenic Shock is a treatable illness with a

reasonable chance for full recovery.


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THANK YOU

Cardiogenic Shock

Mochamad Yusuf

2013


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VASOPRESSORS AND INOTROPES


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ESC ALGORITHM

ESC 2012


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TAKE HOME MESSAGE

KNOW YOUR ENEMY

TREAT UNDERLYING DISEASE

SUPPORT HEMODYNAMICS

BE FAST


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LEFT VENTRICULAR ASSIST DEVICES (LVAD)

MECHANICAL SUPPORT


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MECHANICAL SUPPORT


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MECHANICAL SUPPORT


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MECHANICAL SUPPORT


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INITIAL MANAGEMENT


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IABP-SHOCK Trial

MECHANICAL SUPPORT


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MECHANICAL SUPPORT

IABP-SHOCK Trial II

5.2 Dr.yusuf Assegaf SpJP - Syok Kardiogenik

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