ACC/AHA Guidelines

Cardiac Pulmonary Edema

and Cardiogenic Shock

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.

Otto Frank and Ernest Starling

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Pulmonary Edema Flow

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

Cardiogenic shock (CS) is a state of

inadequate tissue perfusion due to cardiac
dysfunction, and complicates 7-10% of
cases of acute myocardial infarction
Without treatment, cardiogenic shock is
associated with a 70-80% mortality rate,
and is the leading cause of death in
patients hospitalized for an acute
myocardial infarction

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ACC/AHA Guidelines

Classic Criteria for Diagnosis of Cardiogenic Shock

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

Frequency of CS Has Remained Steady Over Time

Frequency of Cardiogenic Shock : 7-9%

NRMI STEMI Registry

N=25,311 Babaev et al JAMA 2005 294:448
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Pathophysiology of Cardiogenic Shock

Causes of Cardiogenic Shock

SHOCK Trial and Registry (N=1160)

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Ventricular Septal Rupture

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Ventricular Septal Rupture

Incidence 1-2% Echo

Timing 2-5 d p MI IABP
PE murmur 90% Inotropic Support
Thrill common Surgical Timing is
Echo shunt controversial, but
PA cath O2 step up > 9% usually < 48 h

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ACC/AHA Guidelines

Free Wall Rupture

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Free Wall Rupture

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

Acute Mitral Regurgitation

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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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Right Ventricular Infarction: Diagnosis

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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ACC/AHA Guidelines

Management of RV Infarction

Cardiogenic Shock secondary to RV Infarct has better

prognosis than LV Pump Failure
IV Fluid Administration
IABP
Dobutamine
Maintain A-V Synchrony
Mortality with Successful Reperfusion = 2% vs.
Unsuccessful = 58%

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The Shock Trial has been the most important study

for management guidelines in patients with
cardiogenic shock

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Hochman et al NEJM 1999;341:625

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ACC/AHA Guidelines

The SHOCK Trial (N=302)

Randomization from Apr 1993-Nov 1998

Primary Endpoint: Overall 30 day mortality

Seconday Endpoints: 6 month and 1 year mortality 23

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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ACC/AHA Guidelines

PCI v. CABG in the Shock Trial

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SHOCK Trial: Age < 75

Immediate Revascularization Strategy
Medical Stabilization as an Initial Strategy

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

Hochman et al, NEJM 1999; 341:625. 26

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ACC/AHA Guidelines

SHOCK Trial: Age > 75

Immediate Revascularization Strategy
Medical Stabilization as an Initial Strategy
P < .01 P < 0.003

80 80
75.0% 79.2%

60 60
53.1% 56.3%
%
40 40

20 20

0 0
30 Day Mortality 6 Month Mortality

Hochman et al, NEJM 1999; 341:625. 27

NRMI Revascularization Rates Over Time By Age

Mortality rates also decreased for those pts undergoing PCI

Use of PCI increased from 27.4% to 54.4% (p < 0.001)
Use of PCI was the strongest independent predictor of a lower in-
hospital mortality (AOR 0.46; p < 0.001)
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Babaev et al JAMA 2005 294:448

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ACC/AHA Guidelines

6 Yr Outcome of SHOCK All Patients

Hochman et al JAMA 2006; 295:2511 29

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%
50
Diabetes, 27.2%
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30 Prior MI, 23.2%

20 Prior CHF, 15.2%
10
Prior PCI, 9.1%
0

1995 2004 Prior CABG, 12.2%

Babaev et al JAMA 2005 294:448 30

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ACC/AHA Guidelines

Prognosis Is Worse With NSTEMI

likely related to the extent of underlying disease

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Multivariable Mortality Predictors

Increasing age 1,2,3,4,7 and female gender7
Lower left ventricular ejection fraction 4,6
Chronic renal insufficiency7
Initial6 and Final TIMI Flow grade 14
Lower systolic blood pressure 1
Diabetes mellitus 5
Prior MI 2
Increasing time from symptom onset to PCI 1,4
Total Occlusion of the LAD 7Mitral regurgitation
Multivessel PCI (p = 0.040) 1,4,6
1 Webb et al JACC 2003;42:1380 4 Zeymer et al EHJ 2004;25:322 7 Klein et al AJC 2005; 96:35
2 Sutton Heart 2005;91:339 5 Tedesco JV Mayo Clin Proc 2003; 78:561
3 Tedesco AHJ 2003:146; 472 6 Sanborn JACC 2003:42; 1373 32

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ACC/AHA Guidelines

ACC/AHA Guidelines for Cardiogenic Shock

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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ACC/AHA Guidelines for Cardiogenic Shock

Class IIa

1. Pulmonary artery catheter monitoring can be useful for the

management of STEMI patients with cardiogenic shock.

2. Early revascularization, either PCI or CABG, is reasonable for

selected patients > 75 years with ST elevation or new LBBB who
develop shock < 36 hours of MI and who are suitable for
revascularization that is performed < 18 hours of shock.
Patients with good prior functional status who agree to invasive care may be
selected for such an invasive strategy.
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CARDIOGENIC SHOCK
MECHANICAL SUPPORT

IABP Counterpulsation

ECMO

Ventricular assist devices

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IABP

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IABP support was associated with a in mortality:

* NRMI-2 with lysis, from 67% to 49%
* SHOCK Trial, from 63% to 47%

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ACC/AHA Guidelines

Contraindications to IABP

Significant aortic regurgitation

Abdominal aortic aneurysm
Aortic dissection
Uncontrolled septicemia
Uncontrolled bleeding diathesis
Severe bilateral peripheral vascular disease uncorrectable
by peripheral angioplasty or cross-femoral surgery
Bilateral femoral-popliteal bypass grafts for severe
peripheral vascular disease
Grossmans 2000
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ACC/AHA Guidelines for Cardiogenic Shock

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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ACC/AHA Guidelines

ECMO
extracorporeal membrane oxygenation
extracorporeal life support

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ECMO

Short-term cardiopulmonary support

Buy time to decide the next step
Recovery
Transplantation
Long-term device (ventricular assist device)
Operation (CABG, pulmonary embolectomy,..)
Give-up

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ACC/AHA Guidelines

Ventricular Assist Devices

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Ventricular Assist Devices

RVAD, LVAD, BiVAD
Nonpulsatile pump
Placed in parallel with RV, LV or both
ventricles
Adjusted to provide total systemic flow of
2-3 L/min/M2
Complications in 50% of patients:
bleeding
systemic embolism 46

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ACC/AHA Guidelines

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