UNIVERSIDAD RICARDO PALMA

FACULTAD DE MEDICINA HUMANA

V CURSO INTERNACIONAL DE ACTUALIZACIN EN MEDICINA Y CIRUGIA

IV JORNADA DE EDUCACIN MDICA UNIVERSITARIA
CONFERENCIA:
SHOCK CARDIOGNICO
DOCTOR
ALFREDO PALACIO
I N C AP
INSTITUTO NACIONAL DE CARDIOLOGIA
ALFREDO PALACIO

UEES
FACULTAD DE MEDICINA
ENRIQUE ORTEGA MOREIRA

GUAYAQUIL ECUADOR

ACC/AHA 2007 STEMI Guidelines Focused Update

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

REPERFUSION

PREVALENCIA
EN IMA

20%

57%

MORTALIDAD

80%

40% *

+ / IABP

20-50%
70 %

SOBREVIDA IH INTRAHOSPITALARIA

* 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 IMA (40% VI)
IMA DE VENTRICULO DERECHO
RM AGUDA (RUPTURA DE MP)
CIV AGUDA
RUPTURA DE PARED LIBRE
TAPONAMIENTO CARDIACO

SHOCK CARDIOGENICO
PRIMER RX
LIMITAR TAMAO DEL IMA
RESTABLECER REPERFUSION
CORONARIA
CONTROLAR RESPUESTAS
INJURIOSAS

ACTIVIDAD SIMPATICA
SISTEMA SRA
RESISTENCIA PERIFERICA
POST CARGA

SHOCK CARDIOGENICO
CURVAS DE PRESION Y DE PERFUSION CORONARIA

SHOCK CARDIOGENICO
IMA

Injuria Miocardica Irreversible 15 - 20 min

Injuria completa area de riesgo 4 - 6 Hrs
Mayor magnitud del dao
2 - 3 Hrs
Restauracin del flujo para
obtener mayor beneficio 1 - 2 Hrs
Hipteis 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?

First line of action

Second line of action
Third 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

Check Blood Pressure

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

Low Output Cardiogenic Shock

Hypovolemia

Acute Pulmonary Edema

Administer
Fluids
Blood transfusions
Cause-specific
interventions
Consider vasopressors

Arrhythmia

Bradycardia

Check Blood Pressure

Tachycardia

ACC/AHA Guidelines for

Patients With ST-Elevation
Myocardial Infarction

Systolic BP
Greater than 100 mm Hg

Systolic BP
70 to 100 mm Hg
NO signs/symptoms
of shock

Systolic BP
70 to 100 mm Hg
Signs/symptoms
of shock

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

Nitroglycerin
10 to 20 mcg/min IV

Dobutamine
2 to 20
mcg/kg per
minute IV

Dopamine
5 to 15
mcg/kg per
minute 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

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

Probability of Event

SAVE

AIRE

TRACE

Radionuclide
EF 40%

Clinical
and/or
radiographic
signs of HF

Echocardiographic
EF 35%

All-Cause Mortality

0.4
0.35
0.3
0.25

Placebo

0.2

ACE-I

Placebo: 866/2971 (29.1%)

0.15

ACE-I: 702/2995 (23.4%)

0.
1
0.05
0

Years

OR: 0.74 (0.660.83)

0

ACE-I

2995

2250

1617

892

223

Placebo

2971

2184

1521

853

138

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

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.
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

Delayed Onset Shock

Echocardiogram to Rule Out
Mechanical Defects

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

Arrange rapid transfer to invasive

procedure-capable center

IABP
Cardiac Catheterization and Coronary
Angiography

1-2 vessel CAD

Moderate 3-vessel CAD

PCI IRA

PCI IRA

Staged Multivessel
PCI

Severe 3-vessel CAD

Left main CAD

Immediate CABG

Staged CABG

Cannot be
performed

SHOCK CARDIOGENICO
BALON DE CONTRAPULSACION AORTICO (IABP)

CLASE IA
I IIa IIb III
II
I

< 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

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

I IIa IIb III

La ACP Primaria debe realizarse -IA 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

I IIa IIb III

Evidencia objetiva de IMA recurrente

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

46.7%

6 A 12 MESES

53.3%

(P<0.03)

50.0%
66.4%

THE SHOCK TRIAL

ACC/AHA 2007 STEMI Guidelines Focused Update

SHOCK CARDIOGENICO
CLASE II
I IIa IIb III

I IIa IIb III

REVASCULARIZACION TEMPRANA
< 75 AOS
ST
BCRI
SHOCK < 36 HS DEL IMA
INTERVENCION < 18 HORAS
> 75 AOS INDICACION IIaB

CATETER PULMONAR

Right Ventricular Infarction

V4R
Modified from Wellens. N Engl J Med
1999;340:381.

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

SHOCK CARDIOGENICO
SOSPECHA DE IMA VD

STEMI + INESTABILIDAD HEMODINAMICA

INFERIOR

CLASE I
I IIa IIb III

EKG + V4R
ECOCARDIOGRAMA

I IIa IIb III

REPERFUSION TEMPRANA ACP

CORREGIR BRADICARDIA Y ASINCRONIA AV
PRECARGA DERECHA
CARGA INICAL RESPUESTA POSITIVA

OPTIMIZAR VOLUMEN
PV < NORMAL
POSCARGA DERECHA
OPTIMIZAR FUNCION V IZQ.

ASISTENCIA INOTROPICA
CUANDO SOBRECARGA DE VOLUMEN ES INSUFICIENTE

Ventricular
Septal Rupture

Incidence
Timing
Phy Exam
Thrill
Echo
PA cath

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

Free Wall
Rupture

Mitral Regurgitation
(Pap. M. dysfunction)

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

Images:Courtesy of W D Edwards (Mayo Foundation)

Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426.

1-2%
3-5 d p MI
murmur 50%
Rare
Regurg. Jet
c-v wave in PCW

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

CABG

Ventricular
Septal Rupture

SHOCK CARDIOGENICO
ANEURISMA VENTRICULAR
I IIa IIb III

STEMI + AV + ARRITMIA INTRATABLE Y/O SHOCK

ANEURISMECTOMIA + CABC

Atacado de fiebres un indio de Loja llamado Pedro de

Leyva, bebi, para calmar los ardores de la sed, del
agua de un remanso, en cuyas orillas crecan
algunos rboles de quina Con su descubrimiento
vino a Lima y lo comunic a un jesuita, el que,
realizando la feliz curacin de la virreina, prest a la
Humanidad mayor servicio que el fraile que invent la
plvora.
Mendiburo dice que, al principio, encontr el uso de
la quina fuerte oposicin en Europa, y que en
Salamanca se sostuvo que caa en pecado mortal el
mdico que la recetaba, pues sus virtudes eran
debidas a pacto de los peruanos con el diablo.
ACC/AHA 2007 STEMI Guidelines Focused Update

PAZ MUNDIAL

ACC/AHA 2007 STEMI Guidelines Focused Update