UCIC-Unità di Cure Intensive Cardiologiche Cardiologia 1

UCIC-Unità di Cure Intensive Cardiologiche
Cardiologia 1-Emodinamica
Scompenso Cardiaco Avanzato
La Terapia dello Shock Cardiogeno,
Up Date 2016
Fabrizio Oliva
CONVENTION DELLA
CARDIOLOGIA LOMBARDA 2016
Grand HotelGardone, Gardone 15-16 Aprile 2016
Presenter Disclosure Information:
• Grant/Research support: Orion Pharma,Servier Italia
• Speaker’s bureau: Norvartis Pharmaceuticals, Orion
Pharma
• Consultant/Advisory board: St Jude Medical
Shock Cardiogeno
Topics
• Epidemiologia e Prognosi
• Flow Chart Operativa
– Rivascolarizzazione
• Timing
• PCI vs CABG
• Multivessel vs Culprit
– Terapia Medica
– Supporto Meccanico
UCIC-Unità di Cure Intensive Cardiologiche
Cardiologia 1-Emodinamica
UCIC-Unità di Cure Intensive Cardiologiche
Cardiologia 1-Emodinamica
Harjola VP
Harjola VP EJHF 2015
De Luca et al - EJHF 2015
IN-HF Outcome
Acute HF: All-cause mortality
by clinical profile at entry
38.1%
32.2%
24.0%
23.4%
22.6%
22.6%
(n. 164)
(n. 814)
15.8%
(n. 1855)
(n. 239)
(n. 42)
(n. 501)
Oliva et al EJHF 2012
(n. 95)
Early Risk Stratification
Harjola EJHF 2015
Cardiogenic Shock (CS) in AMI
Pathophysiology-Current Concept
Trattamento dello Shock che complica l’Infarto Miocardico
Thiele H et al, , Eur Heart J 2015
ESC Guidelines on STEMI, Eur Heart J 2012,
ESC Guidelines on myocardial rev. Eur Heart J 2014
Trattamento dello Shock che complica NonSTEMI
ESC Guidelines on NonSTEMI, Eur Heart J Sep 2015
UCIC-Unità di Cure Intensive Cardiologiche
Cardiologia 1-Emodinamica
Rivascolarizzazione
Timing
Timing of Revascularization
JACC 2003
UCIC-Unità di Cure Intensive Cardiologiche
Cardiologia 1-Emodinamica
Rivascolarizzazione
PCI vs CABG
CABG vs PCI ?
Although the mode of revascularization was not
randomized in the SHOCK TRIAL, survival was similar
in patients treated with PCI and CABG
CABG should be reserved for patients with mechanical
complications or coronary anatomy not amenable to
PCI who have ongoing CS
White HD, Assmann SF, Sanborn TA, et al. Comparison of percutaneous coronary
intervention and coronary artery bypass grafting after acute myocardial infarction
complicated by cardiogenic shock: results from the Should We Emergently
Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial. Circulation.
2005;112:1992–2001
UCIC-Unità di Cure Intensive Cardiologiche
Cardiologia 1-Emodinamica
Rivascolarizzazione
Culprit vs Multivessel
Culprit vs Multivessel
Mylotte D JACC Int 2013
Immediate multivessel percutaneous coronary intervention versus culprit lesion
intervention in patients with acute myocardial infarction complicated by cardiogenic
shock: results of the ALKK-PCI registry.
Zeymer U, Hochadel M, Thiele H, Andresen D, Schühlen H, Brachmann J, Elsässer A, Gitt A, Zahn R
Aims: Current guidelines recommend immediate multivessel percutaneous coronary
intervention (PCI) in patients with cardiogenic shock, despite the lack of randomised
trials. We sought to investigate the use and impact on outcome of multivessel PCI in
current practice in cardiogenic shock in Germany. Methods and results: Between
January 2008 and December 2011 a total of 735 consecutive patients with acute
myocardial infarction, cardiogenic shock and multivessel coronary artery disease
underwent immediate PCI in 41 hospitals in Germany. Of these, 173 (23.5%) patients
were treated with immediate multivessel PCI. The acute success of PCI with respect to
TIMI 3 flow did not differ between the groups (82.5% versus 79.6%). In-hospital mortality
with multivessel PCI and culprit lesion PCI was 46.8% and 35.8%, respectively. In
multivariate analysis multivessel PCI was associated with an increased mortality
(odds ratio 1.5; 95% confidence interval 1.15-1.84). Conclusions: In current clinical
practice in Germany multivessel PCI is used only in one quarter of patients with
cardiogenic shock treated with primary PCI. We observed an adverse effect of
immediate multivessel PCI. Therefore, a randomised trial is needed to determine the
definitive role of multivessel PCI in cardiogenic shock.
(Culprit-Shock Trial, NCT01927549)
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society
of Cardiology, August 2014
UCIC-Unità di Cure Intensive Cardiologiche
Cardiologia 1-Emodinamica
Shock
TERAPIA FARMACOLOGICA
Inotropic/Vasopressor support
Inotropic/Vasopressor support
Werdan K
Russ et al Crit Care Med 2007
Munich, January 22th, 2016
Recommendations for the use of levosimendan
in Acute Heart Failure and Cardiogenic Shock complicating
ACS: a review and expert consensus opinion
•
•
•
•
No benefits
Type I: ACS + congestion, BP > 120mmHg, HR increased
An option
Type II: ACS+ low or normal HR, worsening congestion, BP decreasing
An option
Type III: Large infarction, congestion/ pulmonary oedema, BP decreasing
Type IV: Large complicated infarction, BP decreases, diuresis
Should be considered
decreases, - CS immediately at entry or at early hospitalisation
Niemen et Al Submitted
UCIC-Unità di Cure Intensive Cardiologiche
Cardiologia 1-Emodinamica
Shock e IMA
SUPPORTO MECCANICO
ESC Guidelines Myocardial Revascularization 2014
N Eng J Med 2012; 367: 1287-1296
Lancet 2013; 382; 1638-1645
BUT…
• Scenario: CS complicating AMI, early revascularization
planned.
• Slightly lower mortality compared other trials and
registries.
• Exclusion of AMI mechanical complications
• 87% device implantion after procedure
• High rate of catecholamine use (90%) may offset the
potential benefit of IABP.
• Exclusion criterion of onset shock > 12 h selected for a
disease more amenable to revascularization.
• Benefit in severe CS is still unsettled
UCIC-Unità di Cure Intensive Cardiologiche
Cardiologia 1-Emodinamica
Trattatamento dello Shock
Supporto Circolatorio Meccanico
Seyfarth JACC 2008
Sheu J-J Crit Care Med 2010
Trends in MCS
in AMI with CS
• Strong evidence suggests that IABP does not reduce mortality
• Impella CP could be a option in pts that require more than
LD vasopressor or multivessel PCI
• Reserve ECMO for pts you cannot oxygenate or do not tolerate
Impella due to emolysis
• MCS should be initiated as early as possible to prevent
permanent organ dysfunction
Studio
AltSHOCK
FLOW CHART
Dott.Fabrizio Oliva
ASST Niguarda Milano
Dott.Michele Senni
ASST Papa Giovanni XXIII
Dott. Emanuele Catena
ASST Fatebenefratelli Sacco
Dott. Elena Corrada
Istituto Clinico Humanitas
Prof. Stefano Carugo
ASST Santi Paolo e Carlo
Dott. Francesco Gentile
ASST Nord Milano
Ospedale Bassini
Dott. Federico Pappalardo
Ospedale San Raffaele
Dott. Marco Negrini
ASST Fatebenefratelli Sacco
Dott. Antonio Mafrici
ASST Santi Paolo e Carlo
THINK BIG. START SMALL.
MOVE FAST
Grazie per l’attenzione