1. How to do Primary Angioplasty - Patients with Cardiogenic Shock Advanced Cardiovascular Intervention 2011 Dan Blackman Leeds General Infirmary

2. MY CONFLICTS OF INTEREST ARE: Research Grants Medicines Company Advisory Board Medicines Company Lilly

3. Causes of Cardiogenic Shock Predominant LV Failure 74.5% Acute Severe MR 8.3% VSD 4.6% Isolated RV Shock 3.4% Tamponade/rupture 1.7% Other 7.5% Shock Registry JACC 2000 35:1063

4. Survival from mechanical causes Shock Registry JACC 2000;36:1104 & 36: 1110 GUSTO 1 Circulation 2000;101:27 Holzer R CCI 2004;61:196

5. Emergency revascularisation - SHOCK Trial 85% of survivors NYHA Class I/II at 12 months Hochman JAMA 2000;285:190 p=0.11 p=0.03 p=0.02

6. Single or Multi-vessel PCI? 81% of PCI patients multi-vessel disease 85% PCI IRA only; 23% complete revascularisation MV PCISV PCICompletePartial p=NS p<0.01 MV PCISV PCI Shock Trial Shock Registry p=NS

7. Role of CABG p=NS SHOCK Trial CABG vs PCI baseline characteristics –LMS Disease 41% vs 13% p=0.051 –3VD 80% vs 60% p=0.18 –Diabetes 49% vs 27% p=0.11 n=47n=81n=276n=109

8. AHA/ACC Guidelines for Revascularisation

9. PCI Strategy in Cardiogenic Shock Stabilise the patient first, open the vessel second Up-front IABP Central venous access Inotropic/Pressor support as required Anaesthetic support in the cath lab

10. De Backer, NEJM, 2010;362:779. 1679 patient RCT in shock 280 patients cardiogenic Increased arrythmia with dopamine (AF/VT/VF) Significantly lower mortality with norepinephrine in CS Vasoconstriction (by SVR) is often absent* Patients with vasoconstriction have better outcome* SOAP II – Comparison of Dopamine and Norepinephrine in Shock

11. Antmen, JACC, 2004;44:671 Cardiogenic Shock Systolic BP >100mmHg Nitroglycerin 10- 20mcg/min Systolic BP 70-100mmHg NO Shock Dobutamine 2-20mcg/kg/min Systolic BP 70-100mmHg With Shock Dopamine 5- 15mcg/kg/min Systolic BP <70mmHg With Shock Norepinephrine 1- 30mcg/kg/min

12. Abciximab in Cardiogenic Shock n=77 n=41n=55 n=113 n=25

13. PRAGUE-7 study 80 patient RCT Up-front (n=40) vs provisional (n=40) abciximab in PPCI for cardiogenic shock P=NS for all

14. Intra-aortic balloon pump counterpulsation

15. IABP in Cardiogenic Shock Primary PCI Retrospective analysis of 23,180 patients from NRMI database 7268 treated by IABP

17. Timing of IABP in Cardiogenic Shock Primary PCI Single centre registry Primary PCI for shock Brodie AJC 1999;84:18

18. Tandem Heart pLVAD Left atrial-to-femoral arterial LVAD Low speed centrifugal continuous flow pump 21F venous transeptal cannula 17F arterial cannula Maximum flow 4L/minute Expensive +++

19. Tandem Heart Outcome Data Improved haemodynamic parameters Increase in bleeding, limb ischaemia, and sepsis Thiele EHJ 2005;26:1276. Burkhoff AHJ 2006;152:e1 p=NS

20. Impella Axial flow pump Much simpler to use Increases cardiac output & unloads LV LP 2.5 –12 F percutaneous approach; Maximum 2.5 L flow LP 5.0 –21 F surgical cutdown; Maximum 5L flow Expensive ++ Pressure Lumen Motor Blood outlet Blood Inlet

21. Impella outcome data ISAR-SHOCK –26 patient RCT Impella vs IABP –  Cardiac Index,  MAP (by 10mmHg) vs IABP –Complications ≤ IABP –No difference in mortality PROTECT-II –654 patients RCT IABP vs Impella in high-risk PCI –Stopped after n= 305 due to futility –Primary EP composite of 10 MAEs –Incidence 38% Impella vs 43% IABP

22. How to treat STEMI + Cardiogenic Shock Emergency angiography and revascularisation On-table echo to rule out mechanical defects Stabilise the patient in the lab before revascularisation –IABP –Central venous access –Pressors if required – Norepinephrine (dopamine) –Anaesthetic support Consider calling the surgeon for true surgical disease PCI culprit artery. Consider other vessels if shock persists. Staged PCI or CABG if patient stabilises Consider percutaneous VAD if shock persists with IABP + effective revascularisation

23. ESC Guidelines for Cardiogenic Shock

24. Revascularisation: SHOCK trial STEMI complicated by shock due to LV failure n= 302 Hypotension (SBP<90mmHg), End organ hypoperfusion, CI 15mmHg Randomised within 36 hours of index event Medical (150) IABP Revasc at 54 hours Emergency Revascularisation (152) PCI or CABG within 6hr IABP recommended Primary endpoint: 30 day mortality Secondary endpoint: 6 and 12 month mortality PCI = 81 and CABG = 47 Late follow-up

25. Heart Attack: The Challlenge, Manchester 2010 Shock: Incidence, Diagnosis, Treatment, Outcome NYHA I-II NYHA III-IV Death Sleeper, JACC, 2005; 46:266.

26. Emergency revascularisation in the Elderly - SHOCK Trial >75 years ERV vs IMS baseline characteristics –LVEF 28% vs 36% p=0.051 –Anterior MI 63% vs 41% p=0.18 –Female 54% vs 31% p=0.11 p=0.01

27. Elderly - SHOCK & other registry data n=44n=233n=61 n=74

28. Why worry about Cardiogenic Shock? Cardiogenic shock complicates 6-8% of STEMI * Mortality is 60.1% ** It is the leading cause of death from STEMI * GUSTO, NRMI, GRACE ** Shock registry JACC 2000

29. ESC Guidelines for Revascularisation Complete revascularisation has been recommended with PCI in all critically stenosed large epicardial coronary arteries

30. Right Ventricular Infarction (3%) Shock with clear lungs Elevated JVP ECG and echo Maintain preload Reduce RV afterload Maintain AV synchrony

31. Mortality by PCI outcomes 3 2 1-0 TIMI FLOW SuccUnsucc PCI Webb, JACC 2003;42:1380.

32. Percutaneous left ventricular assist devices Even with revascularisation and IABP support mortality from cardiogenic shock post STEMI remains ≥50% Recovery of myocardial performance following successful revascularisation may take several days. During this time many patients succumb to low cardiac output Efficacy of IABP is limited by the lack of active cardiac support, requirement for a certain level of LV function, and the need for accurate synchronisation with cardiac cycle Patients with severely impaired LV function and/or persistent tachyarrhythmias derive little benefit from IABP

33. Management Principles Diagnose & treat causes other than LV failure Support cardiac output and organ perfusion –Inotropes / pressors –Mechanical support Early Revascularisation PCI/CABG

34. Inotropes and Vasopressors AgentDose μg/min α vasoconstrict β Inotropy/vasodilate Arrhythmia Epinephrine2-10+++++ Norepinephrine0.5-30+++++ Dopamine 5-10++ 10-20+++ Dobutamine2-20++++++ Isoproterenol2-100+++ Vasoconstriction (by SVR) is often absent* Patients with vasoconstriction have better outcome* * SHOCK Data

35. PCI + staged CABG Chiu et al Single centre retrospective registry study PCI only vs PCI + staged CABG for cardiogenic shock with multivessel disease Propensity matched n=44 in each group 1.3 vessels revascularised by PCI; 2.6 by CABG 30-day mortality 20.5% PCI + CABG vs 40.9% PCI only