Athanassios Antonopoulos MD, PhD, FESC, FACC U.O. Cardiologia Faenza (RA), Emilia Romagna, IT
Athanassios Antonopoulos MD, PhD, FESC, FACCU.O. Cardiologia Faenza (RA), Emilia Romagna, IT
No conflict of interest
Goldberg RJ et al, Circulation 2009
Goldberg RJ et al, Circulation 2009
mortality
SHOCK Trial: Age < 75
0
20
40
60
80
30 Day Mortality
41.4%
56.8%%
P < .01
0
20
40
60
80
6 Month Mortality
44.9%
65.0%
Hochman et al, NEJM 1999; 341:625.
Immediate Revascularization StrategyMedical Stabilization as an Initial Strategy
P < 0.002
SHOCK Trial: Age > 75
0
20
40
60
80
30 Day Mortality
75.0%
53.1%%
P < .01
0
20
40
60
80
6 Month Mortality
79.2%
56.3%
Hochman et al, NEJM 1999; 341:625.
Immediate Revascularization StrategyMedical Stabilization as an Initial Strategy
P < 0.003
Long-term follow-up of the SHOCK trial cohort. Early revascularization (ERV) is associated with sustained benefit.
Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697
Copyright © American Heart Association, Inc. All rights reserved.
Functional status in the SHOCK trial. The majority of patients who survived 2 weeks after discharge had good functional status (and quality of life) at that time point.
Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697
Copyright © American Heart Association, Inc. All rights reserved.
Causes
Cardiogenic shock is a spectrum
Range of LVEF in studies of heart failure and in the SHOCK trial.
Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697
Figure 3. Iatrogenic shock.
Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697
SHOCK Trial
Tsuneyoshi I Crit Care Med 2001; 29:487
Levosimedan very early in cardiogenic shock, effects lasting for at least 72 h,no pro-arrhythmic effects
IMPORTANT
Algorithm for revascularization strategy in cardiogenic shock, from ACC/AHA guidelines. Whether shock onset occurs early or late after MI, rapid IABP placement and
angiography are recommended.
Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697
Sheidt, NEJM 1973; Mueller, Circ 1972
One complete cardiac cycle and the corresponding waveform of the IABP during inflation and deflation.
Murli Krishna, and Kai Zacharowski Contin Educ Anaesth Crit Care Pain 2009;9:24-28
© The Board of Management and Trustees of the British Journal of [2009]. All rights reserved. For Permissions, please email: [email protected]
Remember the IABP curve …
Endocardial Viability Ratio: DPTI / TTI
DPTI= the net area between aortic pressure and left ventricular pressure during diastole. TTI= the area under the LV systolic curve is well correlated w myocardial oxygen demand for total left ventricular work
DPTI = oxygen supply
TTI = oxygen demand
Prondzinsky et al. SHOCK 2012;37:378-384
Gaps !
patients for surgery
Perera, et al ACC 2012
IABP in high risk pts for non-cardiac surgery
patients with coronary artery disease (CAD) for whom bypass grafting is not an option due to: (1) inoperable CAD; (2) a severe coexisting disease process (such as a malignancy); or (3) the emergent nature of the noncardiac procedure.
The decision analysis suggests that patients whose preoperative assessment places them at very high risk for postoperative complications (Goldman class IV or Detsky class III undergoing major surgery) may benefit the most from prophylactic placement of an IABP prior to noncardiac surgery.
Thank you….