Cardiogenic Shock: less stress for the pump

M. MaggioriniIntensive Care Unit

Department of Internal Medicine

University Hospital Zurich(member of Pulsion medical advisory board)

Clinical Course of Chronic Heart Failurecharacterized by acute decompensation

Death

Clin

ical

Sta

tus

Time (Years)

Compensated

Acutely Decompensated Hospitalizations

Chronically Decompensated

NYHA I II III IV

Episode of Acute Decompensation

Admission to ICU fro Inotropic Treatment

Prognosis of Patients with AHF admitted to the ICU

Adamopoulos et al., Eur. J. Heart Fail., 2007, 9:935

355 patients admitted to the CCU/ICU for acutely decompensate heart failure

Assessment of left ventricular function in acute heart failure

ESC G

uidelines 2005

Clinical assessment of the acute heart failure patient

Ad

apted

from N

ohria, JAM

A, 287, 2002

Adeq

uate

Per

iphe

ral P

erfu

sion

Warm / Dry Warm and Wet

Cold / Dry Cold and Wet

A B

L C

Pulmonary congestion

Clinics and Hemodynamics of cardiogenic shock: Forrester classification

Cardiac filling pressureForrester Am J Cardiol 1977 39:137

Normal

Hypovolemicshock

Pulmonaryedema

PAOP > 18 mmHg

< 2.2 l.min-1.m2

Car

diac

inde

x

Tiss

ue p

erfu

sion

Warm / DryWarm / Dry Warm / WetWarm / Wet

Cold / DryCold / Dry Cold / WetCold / Wet

Pulmonary congestion

A B

L C

CardiogenicShock

To restore cardiac function in order to meet body oxygen requirements, hence improve oxygen supply and organs perfusion.

Goals for the treatment of AHF in the ICU(ESC Guidelines 2005)

Hemodynamic goals (ESC Guidelines)Cardiac Index > 2.2 l.m-1.m2

Mean blood pressure > 70 mmHgPulmonary artery occlusion pressure < 18 mmHg

Clinical goalsReduction of the clinical symptoms and signs of heart failure, restore oxygenation and diuresis ESC

Guidelines 2005

Relationship between LVEF and hemodynamics on ICU admission

Uriel et al.et al., Eur. J. Heart Fail., 2005, 7:815

344 patients admitted to ICU with acute decompensated congestive heart failure

MAP (mmHg) 81 ± 14 86 + 16 92 ± 13 95 ± 14 p < 0.0001RAP (mmHg) 13 ± 7 13 ± 6 14 ± 6 16 ± 7 nsPAOP (mmHg) 26 ± 6 25 ± 6 26 ± 6 26 ± 6 ns

LVEF%

P < 0.0003Cardiac Index

(l/min/m2)

Targeting PAOP < 15 mmHg doesn't affect time to clinical resolution of congestion

ESCAPE Trial, JAMA 2005, 294:1695

Days alive and out of hospital Impact of intervention across subgroups

Acute Heart Failure

yesAdequate cardiac power?

yes

Reversal of metabolic acidosis, ScvO2 > 65%, clinical signs of adequate organ perfusion

Acute Heart Failure

Art. oxygen saturation > 95% ?

FiO2 �, ev. CPAP, NIPPV

Immediate resuscitation?Patient distressed or in pain?

CPR, Analgesia and sedation

Mean BP > 70mmHg ? Vasodilators, consider diuresis if volume overload

no

no

yes

yes

yesNormal heart rate and rhythm? Pacing, atiarrhythmics etc.no

yes

Clinic, Chest-x-ray, EVLW

Arterial line

ECG

Adequate Preload ? Volume bolus

nono Global end-diastolic volume

Adequate cardiac output ? no CO (Themodilution)ScvO2

yesInotropics

monitoring treatment

Adapted from ESC Guidelines 2005

no Cardiac power output, Cardiac function index

Cardiac power output

Definition: Is the power of the punp required to move blood trough the circulation

Cardiac power output (CPO) = cardiovascular flow * mean forward pressure

Cotter et al. Curr Opin Cardiol 2003, 18:215

CPO (Watt) = (CO * MAP) / 451

Cardiac Index and PAOP in differentconditions of acute heart failure

Cardiac Index

Car

diog

enic

sh

ock

Pulm

onar

y ed

ema

HTN

cris

is

Exac

erba

ted

syst

. CH

F

Nor

mal

Sept

ic

shoc

k

Car

diog

enic

sh

ock

Pulm

onar

y ed

ema

HTN

cris

is

Exac

erba

ted

syst

. CH

F

Nor

mal

Sept

ic

shoc

k

Pulmonary artery occlusion pressure

Cotter et al. Eur J Heart Failure 2003, 5:443

Cardiac power output in differentconditions of acute heart failure

Car

diog

enic

sh

ock

Pulm

onar

y ed

ema

HTN

cris

is

Exac

erba

ted

syst

. CH

F

Nor

mal

Sept

ic

shoc

k

Pulmonary artery occlusion pressureCardiac Power Index

Car

diog

enic

sh

ock

Pulm

onar

y ed

ema

HTN

cris

is

Exac

erba

ted

syst

. CH

F

Nor

mal

Sept

ic

shoc

k

Cotter et al. Eur J Heart Failure 2003, 5:443

Assessment of Cardiac Power Output using the PiCCO monitor

Blood Flow / Enddiastolic Volume relationship

GEDVI (ml/m2)0 200 400 600 800 1000 1200

2.5

5.0

7.5

10.0

CI (

l/min

/m2 )

area to meet

Normal

Heart failure

• CFI = CI/GEDVI• GEF = (CI/HR)/GEDVI

0.0

2.0

4.0

6.0

8.0

10.0 CFI (1/min)

Heart failure Sepsis

P<0.001

Cardiac Funtion Index

Ritter et al. (submitted)

Cardiac function index as a marker of cardiac performance

4 consequitive measurement within 19 hours in 12 acute heart failure patients Relationship between cardiac function index and left ventricular stroke work index or cardiac power output

Ritter et al. Submitted 2008

Pulmonary artery occlusion pressure and mixed venous oxygen saturation as

markers of cardiac performance4 consequitive measurement within 19 hours in 12 acute heart failure patients

Relationship between cardiac function index and PAOP or SmvO2

Ritter et al. Submitted 2008

Mean arterialMean arterialpressurepressure

Cardiac Cardiac OutputOutput

Heart rate

MyocardialContractility

Total systemic vascular resistance

Hemodynamic management using the PiCCO monitoring system

PreloadGEDVI

(600-1000 ml/m2)

Flow = pressure / resistance

Pressure = Flow * resistance

CPO = Flow * pressure

Cardiac power output• CO * MAP / 451• Cardiac Function Index• Global ejection Fraction

Pulmonary vascular permeability index (PVPI) for the assessment of

hydrostatic pulmonary edema

PVPI PVPI = = EVLW EVLW / / PBVPBV

3 elements

Pulmonary venous hypertensionPulmonary Blood Volume (PBV)Pulmonary vascular permeability

Monnet et al. Intensive Care Med 2007, 33:400

PVPI

PVPI PVPI = = EVLW EVLW / / PBVPBV

ALI/ARDS Hydrostatic pulmonary edema

Monitoring changes in EVLW after ICU admission: a prognostic marker

3 elements

Pulmonary venous hypertensionPulmonary Blood Volume (PBV)Pulmonary vascular permeability

Ritter et al ESICM Berlin 2007

EVLW Evolution Cardiogenic pulmonary edemChanges During first 3 ICU Days

Mean (SD) in Percent

22.4% (10)

6.2% (20)

0

5

10

15

20

25

30

Survivors Non SurvivorsPe

rcen

t (%

)(17 Pts) (9 Pts)

P = 0.03

Hochman JS Circ 2003, 107:2998

↑ iNOS

Systemic inflammation

Inflammatory cytokines

NO↑ONOO

Vasodilation↑ Vessel permeability

↓ Systemic perfusion

↓ Coronary perfusion pressure

Permeability type of Pulmonary edema

↑LVEDPPulmonary congestion

Myocardial InfarctionMyocardial Dysfunction

Systolic Diastolic

Death