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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

THE SHOCK TRIAL JAMA 2001; 285: 190-2

SHOCK CARDIOGENICO
PREREPERFUSION PREVALENCIA EN IMA
MORTALIDAD SOBREVIDA IH INTRAHOSPITALARIA

REPERFUSION 57%
40% * 20-50% 70 %

20%
80%

+ / IABP

* SIGUE SIENDO LA 1 CAUSA DE


MUERTE IH EN EL IMA (TAMI) I TRIAL CIRCULATION 1988; 77: 1090-90 NEJM 1991; 325: 1117-22 JACC 1992; 20: 1982-9

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

ACC/AHA 2007 STEMI Guidelines Focused Update

SHOCK CARDIOGENICO
CURVAS DE PRESION Y DE PERFUSION CORONARIA

SHOCK CARDIOGENICO IAM


Lesin Miocardica Irreversible 15 - 20 min Lesin completa area de riesgo 4 - 6 Hrs Mayor magnitud del dao 2 - 3 Hrs Restauracin del flujo para obtener mayor beneficio 1 - 2 Hrs Hiptesis de arteria abierta flujo normal mortalidad Tamao de infarto lo anterior mas colaterales

Emergency Management of Complicated STEMI


Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema Most likely major underlying disturbance? Acute Pulmonary Edema
Hypovolemia

Low Output Cardiogenic Shock

Arrhythmia

First line of action

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

Administer Fluids Blood transfusions Cause-specific interventions Consider vasopressors

Bradycardia

Tachycardia

Check Blood Pressure ACC/AHA Guidelines for Patients With ST-Elevation Myocardial Infarction

Second line of action

Check Blood Pressure Systolic BP Greater than 100 mm Hg and not less than 30 mm Hg below baseline

Systolic BP Greater than 100 mm Hg

Systolic BP 70 to 100 mm Hg NO signs/symptoms of shock Dobutamine 2 to 20 mcg/kg per minute IV

Systolic BP 70 to 100 mm Hg Signs/symptoms of shock Dopamine 5 to 15 mcg/kg per minute IV

Systolic BP less than 70 mm Hg Signs/symptoms of shock

Nitroglycerin 10 to 20 mcg/min IV

Norepinephrine 0.5 to 30 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

Third line of action

Circulation 2000;102(suppl I):I-172-I-216.

SAVE

Radionuclide EF 40%

AIRE

Clinical and/or radiographic signs of HF

TRACE

Echocardiographic EF 35%

0.4

All-Cause Mortality

Probability of Event

0.35 0.3 0.25

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

Flather MD, et al. Lancet. 2000;355:15751581

SHOCK CARDIOGENICO IMA


When NOT to give Nitroglycerin
Nitrates should not be administered to patients with:
I IIa IIb III

systolic pressure < 90 mm Hg or to 30 mm Hg below baseline severe bradycardia (< 50 bpm) tachycardia (> 100 bpm) or suspected RV infarction.

I IIa IIb III

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).

SHOCK CARDIOGENICO IMA


EVIDENCE GRADING

I IIa IIb III

BENEFICIAL

HARMFUL

A B C
RANDOMIZED EXPERT OPINION

PCI for Cardiogenic Shock


Cardiogenic Shock
Early Shock, Diagnosed on Hospital Presentation
Fibrinolytic therapy if all of the following are present: 1. Greater than 90 minutes to PCI 2. Less than 3 hours post STEMI onset 3. No contraindications Arrange prompt transfer to invasive procedure-capable center

Delayed Onset Shock Echocardiogram to Rule Out Mechanical Defects


Arrange rapid transfer to invasive procedure-capable center

IABP

Cardiac Catheterization and Coronary Angiography

1-2 vessel CAD

Moderate 3-vessel CAD

Severe 3-vessel CAD

Left main CAD

PCI IRA

PCI IRA

Immediate CABG Cannot be performed

Staged Multivessel PCI

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 + TAQUICARDIA VENTRICULAR POLIMORFA

I IIa IIb III

STEMI + ICC

ACP

ACC/AHA 2007 STEMI Guidelines Focused Update

SHOCK CARDIOGENICO IMA


ACP PRIMARIA O DE RESCATE EN STEMI:
I IIa IIb III

DEBE REALIZARSE IBen pacientes severa (ICC) (Killip clase 3)

con Sx < 12 horas


La ACP Primaria debe realizarse -IAI IIa IIb III en pacientes < 75 aos con elevacin ST o BCRI SHOCK <36 horas post MI, ACP realizable <primeras 18 horas del shock. En pacientes >75 aos: -IIa B-

SHOCK CARDIOGENICO IMA


APC POSTERIOR A FIBRINOLISIS
APC debe ser realizada en pacientes con:
I IIa IIb III

Evidencia objetiva de IMA recurrente

I IIa IIb III

Isquemia miocardica moderada o severa, ya sea espontanea o provocada, durante la recuperacion STEMI

I IIa IIb III

Shock cardiogenico o inestabilidad hemodinamica.

FIBRINOLSIS REPERFUSIN

ACC/AHA 2007 STEMI Guidelines Focused Update

SHOCK CARDIOGENICO
CLASE I

I IIa IIb III

FIBRINOLISIS
CUANDO INTERVENCION ESTA CONTRAINDICADA
I IIa IIb III

MONITOREO HEMODINAMICO INTRAARTERIAL ECOCARDIOGRAFIA (EVIDENCIAR COMPLICACIONES MECANICAS)

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%

THE SHOCK TRIAL


ACC/AHA 2007 STEMI Guidelines Focused Update

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

I IIa IIb III

CATETER PULMONAR

Right Ventricular Infarction


Clinical findings: Shock with clear lungs, elevated JVP Kussmaul sign Hemodynamics: Increased RA pressure (y descent) Square root sign in RV tracing ECG: ST elevation in R sided leads Echo: Depressed RV function Rx: Maintain RV preload Lower RV afterload (PA---PCW) Inotropic support Reperfusion

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

I IIa IIb III

OPTIMIZAR VOLUMEN PV < NORMAL


POSCARGA DERECHA
OPTIMIZAR FUNCION V IZQ.

ASISTENCIA INOTROPICA
CUANDO SOBRECARGA DE VOLUMEN ES INSUFICIENTE

Ventricular Septal Rupture

Free Wall Rupture

Mitral Regurgitation (Pap. M. dysfunction)

Incidence Timing Phy Exam Thrill Echo PA cath

1-2% 3-5 d p MI murmur 90% Common Shunt O2 step up

1-6% 3-6 d p MI JVD, EMD No Peric. Effusion Diast Press Equal.

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

RUPTURA DE MUSCULO PAPILAR

CIRUGIA URGENTE

CONCOMITANTE CABG

Mitral Regurgitation (Pap. M. dysfunction)

SHOCK CARDIOGENICO
RUPTURA SEPTAL O DE PARED LIBRE
I IIa IIb III

CIRUGIA URGENTE

Ventricular Septal Rupture

CABG

SHOCK CARDIOGENICO
ANEURISMA VENTRICULAR
I IIa IIb III

STEMI + AV + ARRITMIA INTRATABLE Y/O SHOCK

ANEURISMECTOMIA + CABC