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Alessandro SionisUnitat de Cures Agudes Cardiològiques
Hospital de la Santa Creu i Sant PauUniversitat Autònoma de Barcelona
1
Codi Shock: Situació Actual al Nostre Entorn
Disclosures (last 5 years)
► Speaker: Abiomed, Astra-Zeneca, Bayer, Boheringher, Ferrer, Getinge-Maquet, Novartis, Orion-Pharma, Sanofi, Servier, Singulex
► Clinical trials: Bristol-Myers Squibb, Cardiorentis, DalCor, Esperion, Ferrer,Janssen, Novartis, Orion-Pharma, Singulex, Zoll
► Research grants: Novartis, Orion-Pharma, Singulex
► Royalties: No
Current In-hospital MortalityUSIK 1995, USIC 2000, FAST-MI France National Registry and CardShock
Modified from Aissaoui et al. Eur Heart J 2012;33:2535
Dea
that
30 d
ays(
%)
70
63
51
44
8,74,2 3,6 3,4
0
10
20
30
40
50
60
70
80
1995 2000 2005 2012
Shock No Shock
Delays in pPCI and in Patients With CS
Kochar A et al. J Am Coll Cardiol Intv 2018;11:1824–33
23,785 STEMI patients from 2012 to 2014 (8.4% had CS)
Delays in pPCI and in Patients With CS
Kochar A et al. J Am Coll Cardiol Intv 2018;11:1824–33
23,785 STEMI patients from 2012 to 2014 (8.4% had CS)
Factors Associated With Mortality for Direct-Presenting CS Patients Factors Associated With Mortality for TrasnferredCS Patients
Impact of STEMI Treatment Delay (FITT-STEMI Trial)
Scholz KH et al. European Heart Journal (2018) 0, 1–10
12,675 STEMI patients
3.31 additional deaths for 100 pPCI
Cardiogenic Shock: Etiology
LVRV
Pericardial
Valvular
Arrhythmias
Aortic dissection
Cardiomyopathies
Pulmonary embolism
Pneumothorax
Myocarditis
STEMI
NSTEMI
Mechanical complications
Cardiogenic Shock in Catalonia 2008-2016
Courtesy of: Pla Director Malalties Cardiovasculars (CatSalut; AQuAS)
An MBDS Analysis of 7,944 hospitalizations (ICD: 785.51)
768719
796 791
912952
919966
923
0
200
400
600
800
1000
1200
2008 2009 2010 2011 2012 2013 2014 2015 2016
20% increase from 2008 to 2016Mortality 55.6 % (from 64.8% to 48.3%)
Cardiogenic Shock in Catalonia 2008-2016
Courtesy of: Pla Director Malalties Cardiovasculars (CatSalut; AQuAS)
An MBDS Analysis of 7,944 hospitalizations (ICD: 785.51)
All MCS No-MCS p
Age (mean; SD) 72.41 (13.4) 64.61 (13.41) 73.54 (13.02) <0.01
Women (%) 38.5 28.9 39.9 <0.01
CAD (%) 50-0 77.4 46.0 <0.01
pPCI (%) 21.0 55.2 16.2 <0.01
CABG (%) 2.8 11.1 1.7 <0.01
Mechanical ventilation (%) 34.9 46.1 33.3 <0.01
CKD (%) 18.7 11.7 11.7 <0.01
Atrial Fibrillation (%) 27.3 17.2 28.7 <0.01
Diabetes (%) 24.9 20.0 25.6 <0.01
PAD (%) 5.2 3.8 5.4 <0.01
Characteristics of Patients Requiring Mechanical Circulatory Support (MCS)
Cardiogenic Shock in Catalonia 2008-2016
Courtesy of: Pla Director Malalties Cardiovasculars (CatSalut; AQuAS)
An MBDS Analysis of 7,944 hospitalizations (ICD: 785.51)
All MCS No-MCS p
IAM-SEST (N; %) 1.167 (15.1%) 162 (16) 1005 (14.8) 0.144
IAM-EST (N; %) 2.118 (27.3) 506 (52) 1612 (23.8) <0.01
Miocarditis (N; %) 88 (1.1) 29 (3.0) 59 (0.9) <0.01
Pulmonary embolism 255 (3.3) 9 (0.7) 246 (3.6) <0.01
Other 4.118 (53.2) 268 (3.4) 3.850 (49.7) <0.01
Patients Requiring Mechanical Circulatory Support (MCS): 974 / 7.746 (12.57%)
Cardiogenic Shock in Catalonia: Use of MCS 2008-2016
Courtesy of: Pla Director Malalties Cardiovasculars (CatSalut; AQuAS)
An MBDS Analysis of 7,944 hospitalizations (ICD: 785.51)
68
55
9892
113
132 134
144138
0
20
40
60
80
100
120
140
160
2008 2009 2010 2011 2012 2013 2014 2015 2016
120% increase from 2008 to 2016
• Pre-Cardiogenic shock
• CS Grade I (mild)
• CS Grade II (profound)
• CS Grade III (advanced)
Different Phenotypes of Cardiogenic Shock
• Mortality?
• Need for catecholamines
• Need for MCS
• Futility?
One Size Does Not Fit All: CS Severity Classification
80%
42%
21%
7.5%3%
Mortality Risk vs Inotrope Dosing
Pre-Shock Mild Shock Profound Shock Refractory Shock
Conv
entio
nal
Devi
ces
Low dose Moderate dose One high-dose Two high-dose Three high-dose
Adapted from: Biswajit Kar at al. Circulation. 2012;125:1809-1817
CS May Not Be Easy to Diagnose In Early Stages
80%
42%
21%
7.5%3%
Mortality Risk vs Inotrope Dosing
Pre-Shock Mild Shock Profound Shock Refractory Shock
Conv
entio
nal
Devi
ces
Low dose Moderate dose One high-dose Two high-dose Three high-dose
Adapted from: Biswajit Kar. Circulation. 2012;125:1809-1817
? ?
Definition of Pre-Shock
Signs of pre-shock or low-flow state. Any of the following unexplained findings in
a patient clinically suspected of being at risk for developing shock:
A. Fall in urine output
B. Rise in heart rate
C. Fall in systolic blood pressure
D. Fall in skin temperature
• Systolic BP<90 mm Hg for 30 minutes or low dose inotrope/vasopressor required to
maintain systolic BP>90 mm Hg
• Pulmonary congestion or elevated LV filling pressure
• Signs of impaired organ perfusion with at least one of the following:
altered mental status
cold clammy skin
oliguria
high lactate (> 2mmol/L)
Cardiogenic Shock Grade I (Mild) Criteria
• Criteria for Cardiogenic shock AND
CI < 2.2 l/min/m OR
lactate > 4 mmol/L
• Despite at least 2 inotropes/vasopressors
Cardiogenic Shock Grade II (Profound) Criteria
• Criteria for advanced cardiogenic shock
• AND two of the following criteria:
lactate > 8 mmol/L
anuria
respiratory failure (NIMV or IMV)
overt RHF
escalating inotropes/vasopressors
Cardiogenic Shock Grade III (Advanced) Criteria
Cardiogenic Shock and Cardiac Arrest ArrestRate of OHCA in Cardiogenic Shock Patients (IABP-SHOCK; CARDSHOCK; CULPRIT-SHOCK)
45,1
28
53,5
0
10
20
30
40
50
60
IABP-SHOCK II CARDSHOCK CULPRIT-SHOCK
Cardiogenic Shock Network: Hub and Spoke Model
Van Diepen S et al. Circulation. 2017;136:e
0
20
40
60
80
100
1 2 3
Ove
rall
surv
ival
(%)
4Time from ECMO implantation (Years)
Cardiac RESCUE
Beurtheret et al. Eur Heart J 2013;34:112
ECMO for Transfer From Non-tertiary Centres (2005-2009)
86% stabilized and transferred
37% discharged alive
Cardiogenic Shock Network: How To Do It
Level 3
Level 2
Level 1
Hub & Spoke Network Model
• Advanced MCS• Heart transplant program
• 24/7 Cath Lab• Short term MCS• ECMO?
• Triage• Initial stabilization• Transfer
Hub
Subh
ubSp
oke
Pre-hospital (Level 0)
Adapted from: Tchantchaleishvili V et al. JAMA Surgery 2015;150: 1025–6
Level 3: Dedicated CS Centers
• Tertiary care centers
• Cardiac catheterization and angioplasty facilities available 24/7
• Advanced MCS and heart transplant options
• On-site cardiothoracic surgery capability
• Established protocol for out-of-hospital cardiac arrest (OHCA)
• A multidisciplinary “cardiogenic shock team”: interventional cardiologist, critical care specialist,
cardiothoracic surgeon, and advanced heart failure specialist
Adapted from: Rab T. et al. J Am Coll Cardiol. 2018;72(16):1972–80
Level 2: STEMI Centers
• Usually tertiary care centers
• Cardiac catheterization and angioplasty facilities available 24/7
• Short-term MCS (Impella®, IABP, ECMO?)
• Usually on-site cardiothoracic surgery capability
• Established protocol for out-of-hospital cardiac arrest (OHCA)
• Clear pathway for Level 3 center referral
Adapted from: Rab T. et al. J Am Coll Cardiol. 2018;72(16):1972–80
Level 1: Community Hospitals
• Usually Community Hospitals
• No on-site cardiac catheterization facilities available 24/7
• No MCS capability
• No on-site cardiothoracic surgery capability
• CS patients should be directly transferred to Level 3 centers
Adapted from: Rab T. et al. J Am Coll Cardiol. 2018;72(16):1972–80
29
Risk Stratification: CardShock Score
Harjola V-P et al. Eur J Heart Fail 2015;17:501-509
EURO-ELSO Registry: SAVE Score
Schmidt M et al. Eur Heart J. 2015;36:2246–56.
AUC 0.68 (95% CI 0.64-0.71)