1. 1. CARDIOGENIC SHOCK THE CHALLENGE Pietro Giuliano U.O. CARDIOLOGIA ARNAS CIVICO PALERMO
2. 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. 3. 40 %
4. 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. 5. The only way to prevent cardiogenic shock in myocardial infarction appears to be very early reperfusion therapy .
6. 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. 7. Caso clinico 2 Caso clinico 1
8. 8. !!!!!!
9. 9. WHY IS THAT ?
10. 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. 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. 12. Iatrogenic Shock Reynolds H R , and Hochman J S Circulation. 2008;117:686-697 Copyright American Heart Association, Inc. All rights reserved.
13. 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. 14. Cardiologists are core centrated They must look at the wole body
15. 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. 16. The inflammatory response. Konrad Reinhart et al. Clin. Microbiol. Rev. 2012;25:609-634
17. 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. 18. Ma ci sono anche belle prospettive Cardiogenic Shock The Challenge
19. 19. Reynolds H R , and Hochman J S Circulation. 2008;117:686-697
20. 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. 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. 22. Good luck !
23. 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.