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Cardiac Pulmonary Edema and Cardiogenic Shock: Frank-Starling Law
Cardiac Pulmonary Edema and Cardiogenic Shock: Frank-Starling Law
Cardiac Pulmonary Edema and Cardiogenic Shock: Frank-Starling Law
Frank-Starling Law
Stroke Volume
End-Diastolic Pressure
In the normal heart, the diastolic volume (preload) is the principal force that
governs the strength of ventricular contraction.
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ACC/AHA Guidelines
P : hydrostatic pressures
: oncotic pressures
Kf : permeability constant of vessel wall
: reflection coefficient
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Pulmonary Edema
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HEMODYNAMIC CHANGES
PROGRESSIVE LEFT HEART FAILURE
Hours
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Cardiogenic Shock
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1. Systemic Hypotension
systolic arterial pressure < 80 mmHg
2. Persistent Hypotension
at least 30 minutes
3. Reduced Systolic Cardiac Function
Cardiac index < 1.8 x m/min
4. Tissue Hypoperfusion
Oliguria, cold extremities, confusion
5. Increased Left Ventricular Filling
Pulmonary capillary wedge pressure > 18 mmHg
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Incidence: 1-6%
Occurs during first week after MI
Classic Patient: Elderly, Female,
Hypertensive
Early thrombolysis reduces incidence but
Late increases risk
Echo: pericardial effusion,
PA cath: equal diastolic pressure
Treat with pericardiocentesis and early
surgical repair 16
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ACC/AHA Guidelines
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Management of Acute MR
Incidence: 1-2%
Echo for Differential Diagnosis:
Free-wall rupture
VSD
Infarct Extension
PA Catheter: large v wave
Afterload Reduction
IABP
Inotropic Therapy
Early Surgical Intervention
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Clinical findings:
Shock with clear lungs,
Elevated JVP
Kussmaul sign
ECG:
ST elevation in R sided leads
Echo:
Depressed RV function
V4R
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Modified from Wellens. N Engl J Med 1999;340:381.
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Management of RV Infarction
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Hochman et al NEJM 1999;341:625
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SHOCK Trial
Primary and Secondary Endpoints
80
P= .027
P=.11
60 63.1%
Mortality (%)
Immediate
56.0% Revascularization
50.3%
40 Strategy
46.7%
Medical Stabilization
as an Initial Strategy
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0
30 Days 6 months
Primary Endpoint Secondary Endpoint
Hochman et al, NEJM 1999; 341:625. 24
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80 80 P < 0.002
P < .01
60 60 65.0%
56.8%
%
40 41.4%
40 44.9%
20 20
0 0
30 Day Mortality 6 Month Mortality
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ACC/AHA Guidelines
80 80
75.0% 79.2%
60 60
53.1% 56.3%
%
40 40
20 20
0 0
30 Day Mortality 6 Month Mortality
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Cardiogenic Shock
NRMI STEMI Registry (N=25,311)
Mortality Rates Over Time Age, 69.4 years
60.3% 47.9%
70
Women, 42.6%
P < 0.001
60 Hypertension, 49.7%
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Diabetes, 27.2%
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ACC/AHA Guidelines
Class I
1. Early revascularization, either PCI or CABG, is
recommended for patients < 75 years old with ST
elevation or new LBBB who develop shock unless further
support is futile due to patients wishes or unsuitability for
further invasive care.
2. Fibrinolytic therapy should be administered to STEMI
patients with cardiogenic shock who are unsuitable for
further invasive care and do not have contraindications
for fibrinolysis.
3. Echocardiography should be used to evaluate
mechanical complications unless assessed by invasively
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Class IIa
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CARDIOGENIC SHOCK
MECHANICAL SUPPORT
IABP Counterpulsation
ECMO
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IABP
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Contraindications to IABP
Class I
1. IABP is recommended for STEMI patients when
cardiogenic shock is not quickly reversed with
pharmacological therapy. The IABP is a
stabilizing measure for angiography and prompt
revascularization.
2. Intra-arterial monitoring is recommended for the
management of STEMI patients with cardiogenic
shock.
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ECMO
extracorporeal membrane oxygenation
extracorporeal life support
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ECMO
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