Cardiogenic-Shock--NT-Cardiovascular-Center:心源性休克-NT心血管中心.ppt
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- Cardiogenic Shock NT Cardiovascular Center 心源性 休克 心血管 中心
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1、Cardiogenic-Shock-NT-Cardiovascular-Center:心源性休克-NT心血管中心Definition90 mmHg15 mmHgSHOCK Registry JACC Sept.2000,Supp.A Spectrum of Clinical PresentationsMortalityRespiratoryDistressHypotensionHypoperfusion21%22%70%60%5.6%28%65%1.4%Risk Factors for Cardiogenic Shock Due to AMI-mediated LV DysfunctionAg
2、e 65Female genderLarge infarctionAnterior infarctionPrior infarctionDMPrior HTNPost-mortem study of Shock heartsAt least 40%of the myocardium infarcted in the aggregate(old and new injury)80%have significant LAD disease2/3 have severe 3VdzOutcomes of Cardiogenic ShockHistoric mortality 60-80%More re
3、cently reported mortality numbers 67%in the SHOCK trial registry 56%in GUSTO-I(v.s.3%in Pts.without shock)Outcomes of Cardiogenic ShockThe 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 poin
4、tOutcomes of Cardiogenic ShockThe SHOCK registry Similar mortality in the two groups 62.5%in non-ST elevation 60.4%with ST elevationPathophysiology of ShockEffect of Hypotension Flow in normal coronary:Regulated by microvascular resistance Coronary flow may be preserved at AO pressures as low as 50
5、mm Hg In coronary vessel with critical stenosis:Vasodilator reserve of microvascular bed is exhausted Decrease in AO pressure=Coronary hypoperfusionPathophysiology of ShockEffect of Hypotension(continued)Normal heart extracts 65%of the O2 present in the blood Little room for augmentation of O2 extra
6、ctionPathophysiology of Shock Effect of:Elevated LVEDP on coronary flowLVEDP(mm Hg)Pathophysiology of ShockHypotension +LVEDP and critical stenosis Myocardial Hypoperfusion LV dysfunction Systemic lactic acidosis Impairment of non-ischemic myocardium worsening hypotension.SchematicLVEDP elevationHyp
7、otensionDecreased coronary perfusionIschemiaFurther myocardial dysfunctionNeurohormonal activation VasoconstrictionEndorgan hypoperfusionMedical Stabilization of Shock Pts.Figure out the volume status,Swan if in doubt Air way Judicious afterload reduction Maintain AV synchrony Dont tolerate Afib Dua
8、l chamber pacing if A-V block 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 1982Kern,et.al.,Circulation 1993 Coronary blood flow velocity was measured using doppler-wire i
9、n nine patients with 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-
10、vivoFuchs,et.al.,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 in
11、creased mean 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-vivoThus balloon pumping increased flow to a bed fed by the critical stenosis,or collateral vesselsIABP in Acute MI
12、JACC 1985IABP in Acute MIqPre-thrombolytic eraqNo Lytics,ASA,or Lopressorq20 patients with Acute MI and“extensive myocardium at risk per baseline Thalium”were Randomized.qPt.s in Shock were excludedStd.Rx:O2,MSo4,Lido,HeparinStd Rx+IABP Plus IV NTGIABP in Acute MIqPatients had repeat Thalium scan on
13、 Day-4qNo 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 clinical benefits:Improved
14、acid-base status Improved urine output Improved mentation Improved overall hemodynamicsAll this,however,does not add up to improved survival without Flow RestorationThrombolysis in Cardiogenic ShockRates of Reperfusion Lower,andRates of Reocclusion HigherThan in non-shock ptsPossible Reason:Diffusio
15、n of thrombolytic agent into the thrombus may be PRESSURE DEPENDENT.BP Effect on efficacy of lytics in ShockDog data LAD occlusion by thrombus Hypotension induced by phlebotomyPrewittJACC 1994;23:784Any Randomized Trials ofThrombolysis in Cardiogenic Shock?Most thrombolytic trials specifically exclu
16、ded patients in cardiogenic shockThe only large placebo-controlled thrombolytic study specifically examining Pts.presenting with shock was GISSI-1 Streptokinase=No BenefitCombined IABP and ThrombolysisGUSTO-I:IABP in 62 of the 310 lytic Rxd Pts.in shockObservational Data:Combined IABP and Thrombolys
17、is Kovack,et.al.,JACC 2019 Stomel,et.al.,Chest 1994Two retrospective observational series from community hospitals:Improved survival from combination Rx.Combined IABP and ThrombolysisObservational Data from SHOCK Registery:Combined IABP and Thrombolysis-Barron,et.al.,AHJ June 2019-National Registry
18、of MI-2,Data base-21,178 pts.Presenting with or developing post-MI shock-32%Received IABPP Selection BiasCombined IABP and ThrombolysisAccompanying 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 ca
19、rdiogenic shock(in conjunction with lytics),randomized trials are clearly needed.”Combined IABP and ThrombolysisThe only randomized trial on the subject:Thrombolysis and Counterpusion to Improve Cardiogenic Shock Survival(TACTICS):Results of a Prospective Randomized Trial.Magnus Ohman,et.al.,Circula
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