How to do Primary Angioplasty

- Patients with Cardiogenic Shock

Advanced Cardiovascular Intervention 2011

Dan Blackman

Leeds General Infirmary

MY CONFLICTS OF INTEREST ARE:

Research GrantsMedicines Company

Advisory BoardMedicines CompanyLilly

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

Survival from mechanical causes

94%

71%

47%

39%

28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

VSD Acute Severe MR

In-h

ospi

tal M

orta

lity

(%)

No SurgerySurgeryPercutaneous closure

Shock Registry JACC 2000;36:1104 & 36: 1110

GUSTO 1 Circulation 2000;101:27

Holzer R CCI 2004;61:196

Emergency revascularisation - SHOCK Trial

47%50%

53%

67%

56%

63%66%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

30 days(n=302)

6 months(n=301)

12 months(n=299)

6 years

Mort

ality

(%

)

ERVIMS

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

Hochman JAMA 2000;285:190

p=0.11p=0.03

p=0.03p=0.02

Single or Multi-vessel PCI?

• 81% of PCI patients multi-vessel disease

• 85% PCI IRA only; 23% complete revascularisation

80%

39%

46%45%50%

54%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1-y

ear

mort

alit

y (%

)

MV PCI SV PCI Complete Partial

p=NS

p<0.01

MV PCI SV PCI

Shock Trial Shock Registry

p=NS

Role of CABG

48%46%

53%

24%

0%

10%

20%

30%

40%

50%

60%

SHOCK Trial SHOCK Registry

1-y

ear

mort

ality

(%

)

PCICABG

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=81 n=276 n=109

AHA/ACC Guidelines for Revascularisation

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

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

Antmen, JACC, 2004;44:671

Abciximab in Cardiogenic Shock

44%

36%

62%

44%

21%22%

26%

39%

22%

9%

0%

10%

20%

30%

40%

50%

60%

70%

Antoniucci(stent)

Chan Stent Chan PTCA Giri (50% stent)

ADMIRAL (stent)

30 d

ay M

ort

alit

y (%

)

PCIPCI +Abciximab

n=77n=41 n=55

n=113n=25

PRAGUE-7 study• 80 patient RCT• Up-front (n=40) vs provisional (n=40) abciximab in PPCI for

cardiogenic shock

100%

37%42%

10%

35%32%

27%

5%

0%

20%

40%

60%

80%

100%

120%

Abciximab given Mortality MACE TIMI Major Bleeding

Eve

nt

rate

(%

)

Up-frontProvisonal

P=NS for all

Intra-aortic balloon pump counterpulsation

63

69

43

59

68

4749

34

45

23

0

10

20

30

40

50

60

70

80

Shock Registry(n=292)

NRMI Registry(n=23,180)

TACTICS GUSTO I & III Kovack (n=46)

Mor

talit

y (%

)

TT onlyTT + IABP

IABP in Cardiogenic Shock Primary PCI

67

49

42

46

0

10

20

30

40

50

60

70

80

Thrombolysis only Thrombolysis + IABP Primary PCI only Primary PCI + IABP

In-h

osp

ital M

ort

ality

(%

)Retrospective analysis of 23,180 patients from NRMI database

7268 treated by IABP

Timing of IABP in Cardiogenic Shock Primary PCI

15%13%

15%

35%

30%

35%

0%

5%

10%

15%

20%

25%

30%

35%

40%

CPR VF/ VT arrest Any event

Eve

nt

rate

(%

)

IABP pre (n=62)IABP post/ none (n=57)

• Single centre registry Primary PCI for shock

Brodie AJC 1999;84:18

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 +++

Tandem Heart Outcome Data

42%

47%45%

36%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

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

30 d

ay m

ort

alit

y (%

)Tandem HeartIABP

Improved haemodynamic parameters

Increase in bleeding, limb ischaemia, and sepsis

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

p=NS

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

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

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

ESC Guidelines for Cardiogenic Shock

Revascularisation: SHOCK trial

Primary endpoint: 30 day mortality Secondary endpoint: 6 and 12 month mortality

PCI = 81 and CABG = 47

Late follow-up

Heart Attack: The Challlenge, Manchester 2010 Shock: Incidence, Diagnosis, Treatment, Outcome

NYHA I-II

NYHA III-IV

Death

Sleeper, JACC, 2005; 46:266.

Emergency revascularisation in the Elderly- SHOCK Trial

41%

75%

57%53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

<75 years (n=246) >75 years (n=56)

30-d

ay M

ort

ality

(%

)ERVIMS

• >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

p=0.01

Elderly - SHOCK & other registry data

48% 47% 46%

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

SHOCK Registry Mayo Clinic Northern NewEngland

30-d

ay M

ort

ality

(%

)

ERVIMS

n=44 n=233 n=61n=74

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

ESC Guidelines for Revascularisation

• Complete revascularisation has been recommended with PCI in all critically stenosed large epicardial coronary arteries

Right Ventricular Infarction (3%)

• Shock with clear lungs • Elevated JVP • ECG and echo

• Maintain preload• Reduce RV afterload• Maintain AV synchrony

Mortality by PCI outcomes

38 39

55

85

100

0

10

20

30

40

50

60

70

80

90

100

1 23 2 1-0TIMI FLOW

SuccUnsuccPCI

Webb, JACC 2003;42:1380.

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

Management Principles

• Diagnose & treat causes other than LV failure

• Support cardiac output and organ perfusion– Inotropes / pressors– Mechanical support

• Early Revascularisation• PCI/CABG

Inotropes and Vasopressors

Agent Doseμg/min

αvasoconstrict

βInotropy/vasodilate

Arrhythmia

Epinephrine 2-10 ++ +++ +++

Norepinephrine 0.5-30 +++ ++ ++

Dopamine

5-10 ++ ++ ++

10-20 +++ +++ +++

Dobutamine 2-20 + +++ ++

Isoproterenol 2-10 0 +++ +++

• Vasoconstriction (by SVR) is often absent* • Patients with vasoconstriction have better outcome*

* SHOCK Data

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