Defining Cardiogenic Shock Identification of Pre-Shock and ... · Cardiogenic Shock Working Group...

Navin K. Kapur, MD, FACC, FSCAI, FAHA

Associate Professor, Department of Medicine

Interventional Cardiology & Advanced Heart Failure Programs

Executive Director, The Cardiovascular Center for Research & Innovation

Defining Cardiogenic ShockIdentification of Pre-Shock and Shock

Relevant Disclosures

Research Funding & Speaker/Consulting Honoraria:

Abiomed, Abbott, Boston Scientific, Maquet, Medtronic, MD Start, Cardiac Assist

Herbert J. Levine

Foundation

Tufts Medical Center

RO1HL139785, RO1H133215

Charlton Award

Tufts Medical Center

10/2007

Anterior MI

LAD PCI and IABPLVEF 20%

11/2007

ReadmittedHeart Failure

LVEF 25%

11/2007

Readmitted - HFICD Implanted

LVEF 25%

3/2008

ReadmittedRecurrent HF

LVEF 25%

4/2009

Readmitted – HF/ACS

Impella Supported

LAD and LCx PCI

LVEF 25%

7/2012

ReadmittedRecurrent HF

LVEF 20%

3/2015

ReadmittedRecurrent HF

LVEF 20%

12/2017

Cardiogenic Shock

Impella + VA-ECMOLVEF 10%

12/2017

Cardiogenic Shock

BiventricularCentrimags

LVEF 10%

4/2018

OrthotopicHeart Transplant

LVEF 65%

Which Cardiogenic Shock Are We Talking About?

AMI-Shock HR-PCI

Advanced HF-ShockAmbulatory Shock

Acute HF Syndromes

Modified from Goodlin. JACC 2009;54:386

Acute MI

Cardiogenic Shock

Advanced HF

Cardiogenic Shock

Which Cardiogenic Shock Are We Talking About?

Our Current Understanding of CGS Physiology

Founded in AMI-Shock

AHA Shock Consensus Statement Circ 2017

Coronary Problem

Ventricular Failure

Vascular Response

Defining Cardiogenic Shock: Exam + Swan

1970-1980s

Defining Cardiogenic Shock: Acute MI 1990

SHOCK Trial (1993-1998): Early Revasc vs Medical Therapy

• Clinical criteria

– SBP<90 mm Hg for at least 30 minutes or

– Supportive measures to maintain SBP>90 mm Hg

– Hypoperfusion (cool extremities, urine output of <30 ml per hour, and HR>60)

• Hemodynamic criteria

– Cardiac index < 2.2 LPM/BSA

– PCWP >15 mm Hg.

– Pulmonary-artery catheterization was not required if anterior MI with CHF.

• Early Shock:

– < 36 hours after myocardial infarction; randomization <12 hours after the

diagnosis of shock

• Exclusion Criteria:

– Severe systemic illness, mechanical or other cause of shock, severe valvular

disease, dilated cardiomyopathy, the inability of care givers to gain access for

catheterization, and unsuitability for revascularization.

Stretch and Bonde JACC 2014

Durable VADs Created Light at the End of the

Advanced HF Tunnel by Defining Patient Profiles

HM-II: BTT Trial

(NEJM 2007)

HM-II: DT Trial

HW: BTT Trial

INTERMACS Profiles : Heart Failure (Stage C-D)

Adapted from Stewart GC Circ 2011

Defining Cardiogenic Shock: Advanced HF 2000

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

BTR Rescue Therapy

2006-2007

2008-2010

2011-2013

INTERMACS Profiles Provided DefinitionData to Support The ‘Go vs No-Go’ Discussion

% o

f D

ura

ble

MC

S D

evic

e Im

pla

nts

Adapted from Kirklin et al JHLT 2014

Higher Mortality with INTERMACS 1 and 2 Patients > 65 years of Age

Rare use of Durable MCS as a Bridge to Recovery or Rescue Therapy Option

Acute MCS (pVADs) May Build that Bridge for

Cardiogenic Shock

Kapur et al Curr HF Rep 2016

Defining Cardiogenic Shock: Exam + Swan

2017 – Back to Killip and Forrester

Time in Cardiogenic Shock

Rx: Multi-organ Support

Unloading, Ventilator, CVVHD

Hemo-Metabolic Problem

Rx: Hemodynamic Support

Circulatory and Ventricular

Hemodynamic Problem

Recovery Death

Kapur and Esposito Curr Cardio Risk 2016 Kapur and Esposito F1000 2017

An Issue of Timing: Diagnosis, Stratification, Therapy

Hemodynamic vs Hemo-Metabolic Shock

Simplifying the Algorithm for AMI-Shock

William O’Neill and Michael Hacala

The Cardiogenic Shock Working Group

Largest US registry of Acute MCS device use in Cardiogenic Shock

Over 500 patients with PA Catheter

Indices

<14 ≥140

20

40

60

80

100

Right Atrial PressureM

ort

ality

(%

)

GFR>47

GFR£47

Renal Profile

p=0.01

p=0.18

p=0.056

p=0.001

p=0.07

<14 ≥140

20

40

60

80

100

Right Atrial Pressure

Mo

rtality

(%

)

Non-Mixed

Mixed

LFT Profile

p=0.01

p=0.15

p=0.45

p=0.004

p=0.15

<14 ≥140

20

40

60

80

100

Right Atrial Pressure

Mo

rtality

(%

)

Non-Mixed

Mixed

LFT Profile

p=0.01

p=0.15

p=0.45

p=0.004

p=0.15

<14 ≥140

20

40

60

80

100

Right Atrial Pressure

Mo

rtality

(%

)

GFR>47

GFR£47

Renal Profile

p=0.01

p=0.18

p=0.056

p=0.001

p=0.07

Morine & Kapur et al. Shock Working Group

Late ShockDeep ShockSevere Shock

Hemo-MetabolicShock

Pre-ShockEarly ShockMild Shock

HemodynamicShock

Hemodynamic vs Hemo-Metabolic Shock

Cardiogenic Shock Working GroupHemodynamic vs Hemo-Metabolic Shock

Cr<1.41 Cr≥1.41 Cr<1.41 Cr≥1.410

20

40

60

80

100

Mo

rtality

(%

)

Impella

ECMO

RAP<14 RAP³14

26 19 19 19 28 32 34 48

*

Cardiogenic Shock Working Group

p=0.09p<0.01

Morine & Kapur et al CSWG TCT 2018

In-H

osp

ital

Mo

ralit

y (%

)

Predictors of Survival at 12-24 hours (N=75)

LA

CTA

TE

CARDIAC POWER OUTPUT

> 0.6

≥4

<4

≤ 0.6

63% Survival

(n=5/8)

30% Survival

(n=3/10)

80% Survival

(n=8/10)

96% Survival

(n=45/47)

Courtesy of William O’Neill

Cardiogenic Shock InitiativeHemodynamic vs Hemo-Metabolic Shock

Strom and Yeh et al. Eurointerv 2018

A Shift in Acute MCS for Cardiogenic Shock

In-hospital Mortality:

MCS vs Non-MCS

33% vs 42%

p<0.001

Defining Cardiogenic ShockIdentification of Pre-Shock and Shock

Thank you

nkapur@tuftsmedicalcenter.org