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Shock Cardiogenico
Shock Cardiogenico
Shock Cardiogenico
DEFINICION:
EVIDENCIA CLINICA DE HIPOPERFUSION CON PRESION ARTERIAL SISTOLICA < 90 mm Hg > 30 min NECESIDAD DE TERAPIA PARA MANTENER PAS > DE 90 mmHg
IC < 2.2 L/ min / m2 PCP (en cua) > 15 mm Hg
SHOCK CARDIOGENICO
PREREPERFUSION PREVALENCIA EN IMA
MORTALIDAD SOBREVIDA IH INTRAHOSPITALARIA
REPERFUSION 57%
40% * 20-50% 70 %
20%
80%
+ / IABP
SHOCK CARDIOGENICO
CAUSAS EXTENSION DEL IAM (40% VI) IAM DE VENTRICULO DERECHO RM AGUDA (RUPTURA DE MP) CIV AGUDA RUPTURA DE PARED LIBRE TAPONAMIENTO CARDIACO Miocardiopata, miocarditis fulminante Contusin miocrdica Bypass prolongado Enfermedad valvular
SHOCK CARDIOGENICO
PRIMER RX
LIMITAR TAMAO DEL IMA RESTABLECER REPERFUSION CORONARIA CONTROLAR RESPUESTAS INJURIOSAS
ACTIVIDAD SIMPATICA SISTEMA SRA RESISTENCIA PERIFERICA POST CARGA
SHOCK CARDIOGENICO
CURVAS DE PRESION Y DE PERFUSION CORONARIA
Arrhythmia
Administer Furosemide IV 0.5 to 1.0 mg/kg Morphine IV 2 to 4 mg Oxygen/intubation as needed Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP greater than 100 mm Hg Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to 100 mm Hg and signs/symptoms of shock present Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70 to 100 mm Hg and no signs/symptoms of shock
Bradycardia
Tachycardia
Check Blood Pressure ACC/AHA Guidelines for Patients With ST-Elevation Myocardial Infarction
Check Blood Pressure Systolic BP Greater than 100 mm Hg and not less than 30 mm Hg below baseline
Nitroglycerin 10 to 20 mcg/min IV
ACE Inhibitors Short-acting agent such as captopril (1 to 6.25 mg) Further diagnostic/therapeutic considerations (should be considered in nonhypovolemic shock) Diagnostic Therapeutic Pulmonary artery catheter Intra-aortic balloon pump Echocardiography Reperfusion/revascularization Angiography for MI/ischemia Additional diagnostic studies
SAVE
Radionuclide EF 40%
AIRE
TRACE
Echocardiographic EF 35%
0.4
All-Cause Mortality
Probability of Event
Placebo ACE-I Placebo: 866/2971 (29.1%) ACE-I: 702/2995 (23.4%) OR: 0.74 (0.660.83)
0 1 2250 2184 2 1617 1521 3 892 853 4 223 138
0.2
0.15 0. 1 0.05 0
Years
ACE-I Placebo 2995 2971
systolic pressure < 90 mm Hg or to 30 mm Hg below baseline severe bradycardia (< 50 bpm) tachycardia (> 100 bpm) or suspected RV infarction.
Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48 hours for tadalafil).
BENEFICIAL
HARMFUL
A B C
RANDOMIZED EXPERT OPINION
IABP
PCI IRA
PCI IRA
Staged CABG
SHOCK CARDIOGENICO
BALON DE CONTRAPULSACION AORTICO (IABP)
CLASE IA
I IIa IIb III
< 75 AOS ST BCRI SHOCK < 36 HS DEL IMA INTERVENCION < 18 HORAS REVASCULARIZACION TEMPRANA
SHOCK CARDIOGENICO
BALON INTRAORTICO DE CONTRAPULSACION (IABP)
CLASE IB
I IIa IIb III
STEMI + PAS < 90 mm Hg PAm < 30 mm Hg STEMI + ESTADO DE BAJO GASTO CARDIACO STEMI + SHOCK SIN RESPUESTA FARMACOLOGICA
CLASE IC
I IIa IIb III
STEMI + DOLOR PRECORDIAL ISQUEMIA RECURRENTE INESTABILIDAD HEMODINAMICA FUNCION VENTRICULAR DEPRIMIDA AREA MIOCARDICA DE RIESGO GRANDE IACB + CAT + CIRUGIA
ACC/AHA 2007 STEMI Guidelines Focused Update
14
SHOCK CARDIOGENICO
BALON INTARORTICO DE CONTRAPULSACION (IABP)
CLASE II a
I IIa IIb III
STEMI + ICC
ACP
Isquemia miocardica moderada o severa, ya sea espontanea o provocada, durante la recuperacion STEMI
FIBRINOLSIS REPERFUSIN
SHOCK CARDIOGENICO
CLASE I
FIBRINOLISIS
CUANDO INTERVENCION ESTA CONTRAINDICADA
I IIa IIb III
SHOCK CARDIOGENICO
REVASCULARIZACION
REVASCULARIZACION DE ESTABILIZACION (P=0.11) EMERGENCIA MEDICA INICAL
MORTALIDAD 30 DIAS
6 A 12 MESES
46.7%
53.3%
(P<0.03)
50.0%
66.4%
21
SHOCK CARDIOGENICO
CLASE II
I IIa IIb III
REVASCULARIZACION TEMPRANA < 75 AOS ST BCRI SHOCK < 36 HS DEL IMA INTERVENCION < 18 HORAS > 75 AOS INDICACION IIaB
CATETER PULMONAR
V4R
Modified from Wellens. N Engl J Med 1999;340:381.
SHOCK CARDIOGENICO
SOSPECHA DE IMA VD STEMI + INESTABILIDAD HEMODINAMICA
INFERIOR
CLASE I
I IIa IIb III
EKG + V4R ECOCARDIOGRAMA REPERFUSION TEMPRANA ACP CORREGIR BRADICARDIA Y ASINCRONIA AV PRECARGA DERECHA CARGA INICAL RESPUESTA POSITIVA
ASISTENCIA INOTROPICA
CUANDO SOBRECARGA DE VOLUMEN ES INSUFICIENTE
1-2% 3-5 d p MI murmur 50% Rare Regurg. Jet c-v wave in PCW
Images:Courtesy of W D Edwards (Mayo Foundation) Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426.
SHOCK CARDIOGENICO
REGURGITACION MITRAL
I IIa IIb III
CIRUGIA URGENTE
CONCOMITANTE CABG
SHOCK CARDIOGENICO
RUPTURA SEPTAL O DE PARED LIBRE
I IIa IIb III
CIRUGIA URGENTE
CABG
SHOCK CARDIOGENICO
ANEURISMA VENTRICULAR
I IIa IIb III
ANEURISMECTOMIA + CABC