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H&P
60 yo m
>24 h of substernal chest pain
Associated with mild dyspnea
Continued to watch TV
The following day came to NMH ED
PMH
PE
ECG
CATH
CATH
During catheterization patients breathing became
very laborious along with profound acidemia
(6.98/44/71)
Urgently intubated
Asystole/3rd degree AVB/hemodynamically stable
VT
TPM
PA catheter PCWP 30, PAP 60
IABP
Cardiogenic Shock
Systemic Hypotension
systolic arterial pressure < 80 mmHg
Persistent Hypotension
at least 30 minutes
Reduced Systolic Cardiac Function
Cardiac index < 1.8 x m/min
Tissue Hypoperfusion
Oliguria, cold extremities, confusion
Increased Left Ventricular Filling
Pulmonary capillary wedge pressure > 18 mmHg
Echo
IABP
Inotropic Support
Surgical Timing is controversial, but usually < 48
Acute MR Management
Echo for Differential Diagnosis:
Free-wall rupture
VSD
Infarct Extension
PA Catheter
Afterload Reduction
IABP
Inotropic Therapy
Early Surgical Intervention
SHOCK Trial
Primary and Secondary Endpoints
P= .027
Mortality (%)
P=.11
63.1%
56.0%
50.3%
46.7%
Primary Endpoint
Secondary Endpoint
Hochman et al, NEJM 1999; 341:625.
P=0.04
80
80
P < .01
60
P < 0.002
60
65.0%
56.8%
40
41.4%
40
20
20
0
30 Day Mortality
44.9%
6 Month Mortality
Hochman et al, NEJM 1999; 341:625.
P < 0.003
P < .01
80
80
75.0%
79.2%
60
60
56.3%
53.1%
40
40
20
20
0
30 Day Mortality
6 Month Mortality
Hochman et al, NEJM 1999; 341:625.
P<0.0001
77%
63%
52%
47%
Thrombolytics
No Thrombolytics
Thrombolytics
+ IABP
+ IABP
+ No IABP
In Hospital Mortality
Neither
IABP
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
RV Infarction Management
Cardiogenic Shock secondary to RV Infarct has better
prognosis than LV Pump Failure
IVF Administration
IABP
Dobutamine
Maintain A-V Synchrony
Mortality with Successful Reperfusion = 2% vs.
Unsuccessful = 58%
2.
3.
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