Transcript of Shock slides mie final copia
- 1. CARDIOGENIC SHOCK THE CHALLENGE Pietro Giuliano U.O.
CARDIOLOGIA ARNAS CIVICO PALERMO
- 2. Non chiederci la parola che squadri da ogni lato l'animo
nostro informe, e a lettere di fuoco lo dichiari e risplenda come
un croco perduto in mezzo a un polveroso prato. Ah l'uomo che se ne
va sicuro, agli altri ed a se stesso amico, e l'ombra sua non cura
che la canicola stampa sopra uno scalcinato muro! Non domandarci la
formula che mondi possa aprirti s qualche storta sillaba e secca
come un ramo. Codesto solo oggi possiamo dirti, ci che non siamo,
ci che non vogliamo. NON CHIEDERCI LA PAROLA Eugenio Montale Ossi
di seppia (1923)
- 3. 40 %
- 4. Figure 5. Long-term follow-up of the SHOCK trial cohort.55
Early revascularization (ERV) is associated with sustained benefit.
Reynolds H R , and Hochman J S Circulation. 2008;117:686-697
Copyright American Heart Association, Inc. All rights
reserved.
- 5. The only way to prevent cardiogenic shock in myocardial
infarction appears to be very early reperfusion therapy .
- 6. 9.1. Cardiogenic Shock 9.1.1. Treatment of Cardiogenic
Shock: Recommendations CLASS I 1. Emergency revascularization with
either PCI or CABG is recommended in suitable patients with
cardiogenic shock due to pump failure after STEMI irrespective of
the time delay from MI onset (212,379,452). (Level of Evidence: B)
2. In the absence of contraindications, fibrinolytic therapy should
be administered to patients with STEMI and cardiogenic shock who
are unsuitable candidates for either PCI or CABG (81,453,454).
(Level of Evidence: B) CLASS IIa 1. The use of intra-aortic balloon
pump (IABP) counterpulsation can be useful for patients with
cardiogenic shock after STEMI who do not quickly stabilize with
pharmacological therapy (455459). (Level of Evidence: B) CLASS IIb
1. Alternative LV assist devices for circulatory support may be
considered in patients with refractory cardiogenic shock. (Level of
Evidence: C)
- 7. Caso clinico 2 Caso clinico 1
- 8. !!!!!!
- 9. WHY IS THAT ?
- 10. Figure 4. Algorithm for revascularization strategy in
cardiogenic shock, from ACC/AHA guidelines.42,44 Whether shock
onset occurs early or late after MI, rapid IABP placement and
angiography are recommended. Reynolds H R , and Hochman J S
Circulation. 2008;117:686-697 Copyright American Heart Association,
Inc. All rights reserved.
- 11. Figure 2. Range of LVEF in studies of heart failure and in
the SHOCK trial. Reynolds H R , and Hochman J S Circulation.
2008;117:686-697 Copyright American Heart Association, Inc. All
rights reserved.
- 12. Iatrogenic Shock Reynolds H R , and Hochman J S
Circulation. 2008;117:686-697 Copyright American Heart Association,
Inc. All rights reserved.
- 13. Figure 1. Current concept of CS pathophysiology. Reynolds H
R , and Hochman J S Circulation. 2008;117:686-697 Copyright
American Heart Association, Inc. All rights reserved.
- 14. Cardiologists are core centrated They must look at the wole
body
- 15. La disfunzione del microcircolo e la risposta infiammatoria
sistemica (SIRS) espongono a danno multi organo (MOF). Il
ripristino non tempestivo della portata sistemica non e` garanzia
di prognosi favorevole. Reynolds and Hochman: CardiogenicShock.
Current Concepts and Improving Outcomes. Circulation.
2008;117:686-697.
- 16. The inflammatory response. Konrad Reinhart et al. Clin.
Microbiol. Rev. 2012;25:609-634
- 17. The reflex mechanism of increased systemic vascular
resistance (SVR) is not fully effective, as demonstrated by
variable SVR, with median SVR during CS in the normal range despite
vasopressor therapy in the SHOCK Trial. In some patients, SVR may
be low, similar to septic shock. In fact, sepsis was suspected in
18% of the SHOCK trial cohort, 74% of whom developed positive
bacterial cultures. SVR was lower in these patients, and low SVR
preceded the clinical diagnosis of infection and culture positivity
by days. These findings are consistent with the observation that MI
can cause the systemic inflammatory response syndrome (SIRS) and
suggest that inappropriate vasodilation as part of SIRS results in
impaired perfusion of the intestinal tract, which enables
transmigration of bacteria and sepsis. SIRS is more common with
increasing duration of shock,
- 18. Ma ci sono anche belle prospettive Cardiogenic Shock The
Challenge
- 19. Reynolds H R , and Hochman J S Circulation.
2008;117:686-697
- 20. Figure 6. Functional status in the SHOCK trial.60 The
majority of patients who survived 2 weeks after discharge had good
functional status (and quality of life) at that time point.
Reynolds H R , and Hochman J S Circulation. 2008;117:686-697
Copyright American Heart Association, Inc. All rights reserved.
Recent evidence challengens the notion that patients with
cardiogenic shock are a lost cause
- 21. Conclusioni? riflessioni.. CS is a treatable illness with a
reasonable chance for full recovery. The CS literature has
traditionally focused on the very high mortality associated with
this diagnosis. It is important to recognize that although patient
s with CS are at very high risk for early death, great potential
exists for salvage. Recent evidence challenges the notion that
patients with CS are a lost cause. In fact, an early invasive
approach can increase short- and long- term survival and can result
in excellent quality of life. Revascularization is associated with
some benefit at every level of risk.
- 22. Good luck !
- 23. Algorithm for revascularization strategy in cardiogenic
shock, from ACC/AHA guidelines.42,44 Whether shock onset occurs
early or late after MI, rapid IABP placement and angiography are
recommended. Reynolds H R , and Hochman J S Circulation.
2008;117:686-697 Copyright American Heart Association, Inc. All
rights reserved.