Hemodynamic Complication of

Acute Coronary Syndrome

SUSI HERMININGSIH, MD FIHA

Department of Cardiology and Vascular Medicine
Dr. Kariadi General Central Hospital
 Definition of Cardiogenic Shock

Systemic hypoperfusion secondary to severe

depression of cardiac output and sustained
systolic arterial hypotension despite elevated
filling pressures.
 Established criteria for Cardiogenic
Shock
• Systolic BP < 90 mmHg for > 30 mnt, or
vasopressors required to achieve BP>/= 90
mmHg.
• Pulmonary congestion or elevated LV filling
pressures.
• Signs of impaired organ perfusion,with at least
one of the following criteria : altered mental
status, cold clammy skin, oliguria, increased
serum lactate.
• Recommended to assess cardiac index and
pulmonary capillary wedges pressure.
 ETIOLOGY
• Acute myocardial
infarction/ischemia
• LV failure
• VSR
• Papillary muscle/chordal
rupture- severe MR
• Ventricular free wall rupture
with subacute tamponade
• Other conditions complicating
large Myocardial Infarctions
– Hemorrhage
– Infection
– Excess negative inotropic or
vasodilator medications
– Prior valvular heart disease
– Hyperglycemia/ketoacidosis
– Post-cardiac arrest
– Post-cardiotomy
– Refractory sustained
tachyarrhythmias
– Acute fulminant myocarditis
– End-stage
cardiomyopathyHypertrophic
cardiomyopathy with severe
outflow obstruction
– Aortic dissection with aortic
insufficiency or tamponade
– Pulmonary embolu
– Severe valvular heart disease -
Critical aortic or mitral stenosis,
Acute severe aortic or MR
 Causes of Cardiogenic Shock
Tamponade/rupture
Other
1.7%
Isolated RV Shock 7.5%
3.4%

VSD
4.6%

Acute Severe MR
8.3%

Shock Registry Predominant LV Failure

JACC 2000 35:1063 74.5%
Pathophysiology
 Clinical Findings
• Physical Exam: elevated JVP, Third heart
sound, crackles, oliguria, acute pulmonary
edema

• Hemodynamics: decrease CO, increase SVR,

decrease SvO2

• Initial evaluation: hemodynamics (PA

catheter), echocardiography, angiography
SHOCK Registry JACC Sept. 2000, Supp. A
Spectrum of Clinical Presentations
Respiratory
Mortality Hypotension Hypoperfusion
Distress

21%

22% 1.4%

70% 5.6%

60% 28%

65%
 Survival from mechanical causes
100% No Surgery
94%
Surgery
90%
Percutaneous closure
80%
71%
In-hospital Mortality (%)

70%

60%

50% 47%
39%
40%

30% 28%

20%

10%

0%
VSD Acute Severe MR
Shock Registry JACC 2000;36:1104 & 36: 1110
GUSTO 1 Circulation 2000;101:27
Holzer R CCI 2004;61:196
Algorhytm Therapy for Cardiogenic Shock
 Potential Therapies

• Pressors
• Intra-aortic Balloon Pump (IABP)
• Fibrinolytics
• Revascularization: CABG/PCI

• Refractory shock: ventricular assist device,

cardiac transplantation
 Inotropes and Vasopressors
No meaningful data!

ACC/AHA Guidelines
SBP <70:-
Norepinephrine (0.5-30 g/min)
Switch to Dopamine (5-15 g/kg/min) once SBP ≥80
SBP 70-100
Dopamine (5-15 g/kg/min)
Add dobutamine (2-20 g/kg/min) once SBP ≥90
 Pressors do not change outcome
• Dopamine
– <2 renal vascular dilation
– <2-10 +chronotropic/inotropic (beta effects)
– >10 vasoconstriction (alpha effects)
• Dobutamine – positive inotrope, vasodilates,
arrhythmogenic at higher doses
• Norepinephrine (Levophed): vasoconstriction,
inotropic stimulant. Should only be used for
refractory hypotension with dec SVR.
• Vasopression – vasoconstriction
• VASO and LEVO should only be used as a last
resort
 “The panel believes that all accessible vessels should be
treated in patients with cardiogenic shock”

“Current Recommendations:-
1-2 vessel disease: PCI IRA
3VD: PCI IRA + staged complete revascularisation

Early MV PCI may be warranted if shock persists despite IRA PCI”

Revascularization – SHOCK trial
Overall 30-Day Survival in the Study

Hochman J et al. N Engl J Med 1999;341:625-634

 Emergency revascularisation –
SHOCK Trial
70% 66%
63%
p=0.03 ERV
p=0.11 IMS
60% 56%
53%
50%
50% 47%
Mortality (%)

40%

30%

20%

10%

0%
30 days (n=302) 6 months (n=301) 12 months (n=299)

85% of survivors NYHA Class I/II at 12 months

Hochman JAMA 2000;285:190
 Single vessel or Multivessel PCI?
- SHOCK Trial
• 81% of PCI patients multivessel disease
• 85% PCI IRA only; 23% complete revascularisation
90%
80%
80%
MV PCI
70%
SV PCI
1-year mortality (%)

p<0.01
60% p=NS
54%
50% 45% 46%

40%

30%

20%

10%

0%
Shock Trial Shock Registry
 Is there a role for CABG – SHOCK Data
60% p=NS
53%

50% 48%
46%
1-year mortality (%)

40%
PCI
CABG
30%
24%

20%

10%

0%
SHOCK Trial SHOCK Registry
n=81 n=47 n=276 n=109

• 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
 Intra-aortic balloon pump counterpulsation

80 TT only
TT + IABP
69 68
70
63
59
60

49
50 47
Mortality (%)

45
43

40
34

30
23

20

10

0
Shock Registry NRMI Registry TACTICS GUSTO I & III Kovack
(n=292) (n=23,180) (n=46)
 IABP in Cardiogenic Shock Primary PCI

Retrospective analysis of 23,180 patients from NRMI database

7268 treated by IABP
80

70 67
In-hospital Mortality (%)

60

49
50 46
42
40

30

20

10

0
Thrombolysis only Thrombolysis + IABP Primary PCI only Primary PCI + IABP
 Timing of IABP in Cardiogenic Shock
Primary PCI
40% IABP pre (n=62)
35% IABP post/none (n=57) 35%
35%

30%
30%
Event rate (%)

25%

20%

15% 15%
15% 13%

10%

5%

0%
CPR VF/VT arrest Any event

• Single centre registry Primary PCI for shock

Brodie AJC 1999;84:18
 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

• If effective, active cardiac support could be provided while

awaiting the beneficial effects of revascularisation, survival
rates may be enhanced
 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
• Cost: 7.5K
 Tandem Heart Outcome Data
p=NS
50%
47% Tandem Heart
45%
45% IABP
42%

40%
36%
30 day mortality (%)

35%

30%

25%

20%

15%

10%

5%

0%
Thiele (n=41) Burkhoff (n=33)

Improved haemodynamic parameters

Increase in bleeding, limb ischaemia, and sepsis

Thiele EHJ 2005;26:1276. Burkhoff AHJ 2006;152:e1

 What we should do about STEMI
Cardiogenic Shock
• Emergency angiography and revascularisation: Primary PCI preferably
– All patients <75 years
– Selected patients ≥75 years

• On-table echo to rule out mechanical defects

• Stabilise the patient in the lab before revascularisation
– IABP
– Pressors if required (Norepinephrine/dopamine)
– Anaesthetic support

• Consider calling the surgeon for true surgical disease

• PCI culprit artery. Other vessels if shock persists
• Use abciximab for PCI
• Consider percutaneous LVAD if shock persists with IABP + multi-vessel
revascularisation