CG Shock

Question 1

Guidelines for CG shock

Answer 1

Multiple guidelines for the treatment of cardiogenic shock recommend hemodynamic support.

Question 2

I use inotropes and balloon pump for my AMI cardiogenic shock patients.

Answer 2

Inotropes and balloon pump are commonly used for cardiogenic shock patients. In the RCT, Shock II, comparing balloon pump to medical management the results revealed no real benefit for either on patient mortality.

Question 3

My hospital does not have a specific protocol for treating cardiogenic shock.

Answer 3

Multiple guidelines for the treatment of cardiogenic shock recommend hemodynamic support.
Well known hazards exist with use of inotropes and balloon pump in the setting of AMI Cardiogenic Shock.
What challenges have you had with inotropes and balloon pump?

Question 4

Using the balloon pump is fast and easy.

Answer 4

Dr. O’Neill published outcomes on Impella Pre-PCI showing 65% survival rates.

Question 5

Guidelines for hemodynamic support in Cardiogenic Shock IABP

Answer 5

IABP is Class III (potential harm) in Europe and now Japan

IABP is Class IIb is U.S.

Question 6

CPO formula

Answer 6

CO x MAP/451 or

CO x MAP x 0.0022

CPO is useful indicator in chronic heart failure (Fincke et al JACC 2004 SHOCK trial) CPO <0.6 = increase in mortality

Question 7

Cotter paper

Answer 7

Categorized acute heart failure patients according to CPO & demonstrated its importance in risk stratification & selection of therapy

Question 8

SHOCK I & SHOCK II (n=600)

Answer 8

NO mortality or hemodynamic benefit IABP vs. Medical Therapy @30 days.

Question 9

Samuels paper

Answer 9

Hospital mortality correlated with number of Inotropes.

1 high dose = 21% mortality
2 high dose = 42% mortality
3 high dose = 80% mortality

“Vasopressors & Inotropes are useful temporizing agents, but their use should be limited to the lowest dose & shortest time interval to limit cardiogenic & end-organ hazard”

Question 10

Sjauw paper

Answer 10

Meta-analysis
Showed IABP increase risk of bleeding & stroke in AMI CGS patients.

Subsequently European Society of Cardiology downgraded IABP to Class III (potential harm) advising IABP should not be used routinely for CGS patients

Question 11

Stretch (Yale) paper

Answer 11

US population study analyzing contemporary use of MCS 2004-2011 & determined that IABP use prior to MCS was a predictor of mortality & increased costs. This is likely due to delayed care in AMI cardiogenic shock patients, according to the authors.

**Be cautious with this as obviously sicker pt. cohort to need IABP support. So a bit of chicken or the egg….

Question 12

ECMO Aso paper (Japan)

Answer 12

No evidence of improved outcome is setting of CGS using ECMO. n=5,263

ECMO best for

• primary pulmonary insufficiency
• newborn or infants w/persistent fetal circulation & respiratory failure
• patients w/acute cardiopulmonary arrest as adjunct to CPR or so-called ECPR

Question 13

ECMO Chung paper

Answer 13

Meta-analysis n=1,866
ECMO for CGS 
Amputation = 4.7%
Stroke = 5.9%
Neurological complications = 13.3%
AKI = 55.6%
Major bleeding = 40.8%
Re-thoracotomy for bleeding or taponade = 41.9%
Significant Infection = 30.4%
Mortality around 70%