最新Cardiogenic Shock - NT Cardiovascular Center:心源性休克- NT心血管中心-文档资料.ppt
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1、Definition,90 mmHg,2.2 li/min.m2,15 mmHg,SHOCK Registry JACC Sept. 2000, Supp. A Spectrum of Clinical Presentations,5.6%,28%,65%,1.4%,Risk Factors for Cardiogenic Shock Due to AMI-mediated LV Dysfunction,Age 65 Female gender Large infarction Anterior infarction Prior infarction DM Prior HTN,Post-mor
2、tem study of Shock hearts,At least 40% of the myocardium infarcted in the aggregate (old and new injury) 80% have significant LAD disease 2/3 have severe 3Vdz,Outcomes of Cardiogenic Shock,Historic mortality 60-80% More recently reported mortality numbers 67% in the SHOCK trial registry 56% in GUSTO
3、-I (v.s. 3% in Pts. without shock),Outcomes of Cardiogenic Shock,The ST pattern in Cardiogenic shock: 15-30 % Non-ST elevation MI Older Mortality: 77% 70-85% ST elevations MI/ New LBBB Mortality: 53-63%,SHOCK registry findings on this point,Outcomes of Cardiogenic Shock,The SHOCK registry Similar mo
4、rtality in the two groups 62.5% in non-ST elevation 60.4% with ST elevation,Pathophysiology of Shock,Effect of Hypotension Flow in normal coronary: Regulated by microvascular resistance Coronary flow may be preserved at AO pressures as low as 50 mm Hg In coronary vessel with critical stenosis: Vasod
5、ilator reserve of microvascular bed is exhausted Decrease in AO pressure = Coronary hypoperfusion,Pathophysiology of Shock,Effect of Hypotension (continued) Normal heart extracts 65% of the O2 present in the blood Little room for augmentation of O2 extraction,Pathophysiology of Shock,Effect of: Elev
6、ated LVEDP on coronary flow,LVEDP (mm Hg),Pathophysiology of Shock,Hypotension + LVEDP and critical stenosis Myocardial Hypoperfusion LV dysfunction Systemic lactic acidosis Impairment of non-ischemic myocardium worsening hypotension.,Schematic,LVEDP elevation Hypotension Decreased coronary perfusio
7、n Ischemia Further myocardial dysfunction Neurohormonal activation Vasoconstriction Endorgan hypoperfusion,Medical Stabilization of Shock Pts.,Figure out the volume status, Swan if in doubt Air way Judicious afterload reduction Maintain AV synchrony Dont tolerate Afib Dual chamber pacing if A-V bloc
8、k present Correct Acid-Base disturbances Maintain BP ( IABP and/or Pressors).,Physiologic Effect of IABP in-vivo,Decreased afterload LV O2 consumption Williams, et.al., Circulation 1982 Kern, et.al., Circulation 1993 Coronary blood flow velocity was measured using doppler-wire in nine patients with
9、critical stenotic lesions. Peak diastolic coronary flow velocity beyond the stenosis was unaffected by intra-aortic balloon pumping. There was unequivocal IABP-mediated augmentation of both proximal and distal coronary blood flow velocities post PTCA.,Physiologic Effect of IABP in-vivo,Fuchs, et.al.
10、, Circulation, 1983 Great cardiac vein flow was measured in seven patients receiving maximal drug therapy and requiring balloon pumping for unstable angina. All patients had greater than 90% stenosis of the proximal LAD coronary artery. Increased great cardiac vein flow correlated with increased mea
11、n aortic diastolic pressure across changes in balloon volumes (off, 20 cc, 30 cc, and 40 cc) and changes in assist ratio (off, 1:4, 1:2, and 1:1) (p = .02).,Physiologic Effect of IABP in-vivo,Thus balloon pumping increased flow to a bed fed by the critical stenosis, or collateral vessels,IABP in Acu
12、te MI,JACC 1985,IABP in Acute MI,Pre-thrombolytic era No Lytics, ASA, or Lopressor 20 patients with Acute MI and “extensive myocardium at risk per baseline Thalium” were Randomized. Pt.s in Shock were excluded,Std. Rx: O2, MSo4, Lido, Heparin,Std Rx + IABP Plus IV NTG,IABP in Acute MI,Patients had r
13、epeat Thalium scan on Day-4 No differences were observed between the two groups regarding: -Thalium defect score comparing days 1 and 4 -The ejection fraction comparing days 1 and 4 = “Unlikely that a mortality benefit is conferred by the IABP/NTG combination”,Utility of IABP in Shock Pts.,Observed
14、clinical benefits: Improved acid-base status Improved urine output Improved mentation Improved overall hemodynamics,All this, however, does not add up to improved survival without Flow Restoration,Thrombolysis in Cardiogenic Shock,Rates of Reperfusion Lower, and Rates of Reocclusion Higher Than in n
15、on-shock pts Possible Reason: Diffusion of thrombolytic agent into the thrombus may be PRESSURE DEPENDENT.,BP Effect on efficacy of lytics in Shock,Dog data LAD occlusion by thrombus Hypotension induced by phlebotomy Prewitt JACC 1994; 23:784,Any Randomized Trials of Thrombolysis in Cardiogenic Shoc
16、k?,Most thrombolytic trials specifically excluded patients in cardiogenic shock The only large placebo-controlled thrombolytic study specifically examining Pts. presenting with shock was GISSI-1 Streptokinase = No Benefit,Combined IABP and Thrombolysis,GUSTO-I: IABP in 62 of the 310 lytic Rxd Pts. i
17、n shock,Observational Data:,Combined IABP and Thrombolysis,Kovack, et. al., JACC 1997 Stomel, et. al., Chest 1994 Two retrospective observational series from community hospitals: Improved survival from combination Rx.,Combined IABP and Thrombolysis,Observational Data from SHOCK Registery:,Combined I
18、ABP and Thrombolysis -Barron, et.al., AHJ June 2001 -National Registry of MI-2, Data base -21,178 pts. Presenting with or developing post-MI shock -32% Received IABP,P0.001,P=NS,TT,TT,IABP,PPTCA,PPTCA,IABP,The younger pts., twice as likely to get TT = Selection Bias,Combined IABP and Thrombolysis,Ac
19、companying Editorial by Magnus Ohman, and Judith Hochman: “Although, there is a wealth of physiologic and outcomes data to support the use of early IABP therapy in cardiogenic shock (in conjunction with lytics), randomized trials are clearly needed.”,Combined IABP and Thrombolysis,The only randomize
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