Recognizing Shock: Diagnosis and Management

Song Li, MD, FACCAdvanced Heart Failure and Transplant Cardiology

University of Washington

10/18/2019

DISCLOSURESong Li, MD

No relevant financial relationship reported.

Cardiogenic Shock Remains a Deadly Condition

• Complicates 6-10% of STEMI

• In-hospital mortality remains high (27%–51%), especially among patients > 75 years old

• 1-year all-cause and HF rehospitalization rates of 59% and 33%

• NYHA class II to IV symptoms at 1 year: 43%

• Average total hospital cost: $41,774

Van Diepen. Circulation. 2017;136:e232–e268.

Definition of Cardiogenic Shock

• Low cardiac output state resulting in life-threatening end-organ hypoperfusion and hypoxia

• The SHOCK, IABP-SHOCK II trials and ESC HF guidelines definitions based on clinical, hemodynamic, and laboratory criteria

• SBP <90 mmHg for ≥30 min• Support to maintain SBP ≥90 mmHg• End-organ hypoperfusion (altered mental status, cold/clammy skin and extremities, urine output

<30 mL/h)• Pulmonary congestion

Clinical criteria

• CI of ≤2.2 L·min−1·m−2

• PCWP ≥15 mmHg

Hemodynamic criteria

• Metabolic acidosis• Elevated serum lactate• Elevated serum creatinine

Laboratory criteria

The SHOCK, IABP-SHOCK II trials and ESC HF 2016 guidelines

Pathophysiology of Cardiogenic Shock

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Shock Phenotypes

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Shock EtiologiesAcute Coronary Syndrome• Myocardial Infarction

• LV• RV

• Mechanical Complications

Acute decompensated HF• Acute on chronic HF• New HF

Postcardiotomy

Others• Valvular• Arrhythmia• Tamponade• Etc.

Management of Cardiogenic Shock

Van Diepen. Circulation. 2017;136:e232–e268.

Vasoactive Drugs

Van Diepen. Circulation. 2017;136:e232–e268.

Tailor to shock etiology. Necessary evil with long-term harm.

Early Revascularization Key For Acute MI and Shock

SHOCK trial, 1999

Hochman, J. et al. JAMA 2006: 295(21), 2511-2515.

CULPRIT-SHOCK, 2018 (MI and Shock) COMPLETE, 2019 (STEMI)

Culprit PCI followed by staged complete revascularization

Culprit vs. Complete Revascularization

Temporary Mechanical Circulatory Support (MCS)

PV Loop and Mechanical Work

Uriel, N. et al. J Am Coll Cardiol. 2018;72(5):569-580

The Spectrum of MCS Options

Atkinson, T. et al. JACC: Cardiovascular Interventions 2016: 9(9), 871-883.

IABP

Burkhoff, D. Nature Reviews Cardiology 2015: 12(7), 383-385.

• Dependent on stable rhythm

• Minimally increases cardiac output

• Increases coronary perfusion pressure

• IABP-SHOCK II trial showed no survival or hemodynamic benefit

VA-ECMO

Burkhoff, D. Nature Reviews Cardiology 2015: 12(7), 383-385. Rao, P., et al. Circulation: Heart Failure 2018: 11(9), e004905.

• Without LV vent, ECMO increases afterload and filling pressure

• Causes LV distention and pulm edema

• Increases mechanical work

• Good for cardiac arrest, BiV failure, and refractory hypoxia

LV Vent is Important for VA-ECMO

Rao, P., et al. Circulation: Heart Failure 2018: 11(9), e004905.

TandemHeart

Burkhoff, D. Nature Reviews Cardiology 2015: 12(7), 383-385.

• Trans-septal puncture

• Provides 3.5 - 5 L/min of flow

• Decreases preload

• Can increase afterload

Impella

Burkhoff, D. Nature Reviews Cardiology 2015: 12(7), 383-385.

• **Directly unloads the LV**

• Reduces LV mechanical work

• Position is key

• LV – AO pressure uncoupling

LV and AO Pressure Uncoupling

Uriel, N. et al. J Am Coll Cardiol. 2018;72(5):569-580

Comparison

Burkhoff, D. Nature Reviews Cardiology 2015: 12(7), 383-385.

Optimizing Cardiogenic Shock Outcomes

Cardiogenic Shock and Timing of MCS

Esposito, M., Kapur, N. F1000Research 2017: 6, 737.

Hemo-Metabolic Shock: Too Late

Morine & Kapur et al. Cardiogenic Shock Working Group

MCS Threshold for Cardiogenic Shock:Too Little or Too Late:

New Concept: Door to Unload

Kapur, N., Davila, C. European Heart Journal 2017: 38(47), 3532-3534

LV unloading before reperfusion may reduce infarct size and LV remodeling

New Concept: Door to Support

Kapur, N., Davila, C. European Heart Journal 2017: 38(47), 3532-3534

Shock Regional Systems of Care

Van Diepen. Circulation. 2017;136:e232–e268.

Shock Team Approach

Taleb, I. et al. Circulation 2019: 140(1), 98-100.

The Cardiogenic Shock Working GroupMulti-Center Acute MCS Registry

Conclusions• Cardiogenic shock remains a condition with high M&M• Early revascularization is key for ACS related cardiogenic shock• “Pumps pump blood; people save lives”

– Understand hemodynamic effects of different MCS platforms– Unload the LV– Initiate MCS before irreversible hemo-metabolic deterioration

• New concepts of “door to unload” and “door to support” are worth studying

• Team-based approach and regional systems of care are promising ways to improve outcomes