UNIVERSIDAD RICARDO PALMA FACULTAD DE MEDICINA HUMANA

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UNIVERSIDAD RICARDO PALMAFACULTAD DE MEDICINA
HUMANA

• V CURSO INTERNACIONAL DE ACTUALIZACIÓN EN
  MEDICINA Y CIRUGIA IV JORNADA DE EDUCACIÓN
  MÉDICA UNIVERSITARIA
• CONFERENCIA
• SHOCK CARDIOGÉNICO
• DOCTOR
• ALFREDO PALACIO
• I N C A P
  
  U E E S
• INSTITUTO NACIONAL DE CARDIOLOGIA
  FACULTAD DE
  MEDICINA
• ALFREDO PALACIO
  
  ENRIQUE ORTEGA MOREIRA
• GUAYAQUIL ECUADOR

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SHOCK CARDIOGENICO

• DEFINICION
• EVIDENCIA CLINICA DE HIPOPERFUSION
• CON PRESION ARTERIAL SISTOLICA lt 90 mm Hg gt 30
  min
• NECESIDAD DE TERAPIA PARA MANTENER PAS gt DE 90
  mmHg
• IC lt 2.2 L/ min / m2
• PCP (en cuña) gt 15 mm Hg

THE SHOCK TRIAL JAMA 2001 285 190-2
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SHOCK CARDIOGENICO
SIGUE SIENDO LA 1ª CAUSA DE MUERTE IH EN EL
IMA
(TAMI) I TRIAL CIRCULATION 1988 77
1090-90 NEJM 1991 325 1117-22 JACC 1992 20
1982-9
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SHOCK CARDIOGENICO

• CAUSAS
• EXTENSION DEL IMA (40 VI)
• IMA DE VENTRICULO DERECHO
• RM AGUDA (RUPTURA DE MP)
• CIV AGUDA
• RUPTURA DE PARED LIBRE
• TAPONAMIENTO CARDIACO

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SHOCK CARDIOGENICO

• PRIMER RX
• LIMITAR TAMAÑO DEL IMA
• RESTABLECER REPERFUSION CORONARIA
• CONTROLAR RESPUESTAS INJURIOSAS
• ACTIVIDAD SIMPATICA
• SISTEMA SRA
• RESISTENCIA PERIFERICA
• POST CARGA

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SHOCK CARDIOGENICO
CURVAS DE PRESION Y DE PERFUSION CORONARIA
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SHOCK CARDIOGENICOIMA

• Injuria Miocardica Irreversible 15 - 20 min
• Injuria completa area de riesgo 4 - 6 Hrs
• Mayor magnitud del daño 2 - 3 Hrs
• Restauración del flujo para
• obtener mayor beneficio 1 - 2 Hrs
• Hipóteis de arteria abierta
• flujo normal mortalidad
• Tamaño de infarto lo anterior mas colaterales

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Emergency Management of Complicated STEMI
Clinical signs Shock, hypoperfusion, congestive
heart failure, acute pulmonary edema Most likely
major underlying disturbance?
Arrhythmia
Low Output - Cardiogenic Shock
Hypovolemia
Acute Pulmonary Edema

• Administer
• Furosemide IV 0.5 to 1.0 mg/kg
• Morphine IV 2 to 4 mg
• Oxygen/intubation as needed
• Nitroglycerin SL, then 10 to 20 mcg/min IV if
  SBP greater than 100 mm Hg
• Dopamine 5 to 15 mcg/kg per minute IV if SBP 70
  to 100 mm Hg and signs/symptoms of shock present
• Dobutamine 2 to 20 mcg/kg per minute IV if SBP
  70 to 100 mm Hg and no signs/symptoms of shock

Bradycardia
Tachycardia

• Administer
• Fluids
• Blood transfusions
• Cause-specific interventions
• Consider vasopressors

First line of action
Check Blood Pressure
ACC/AHA Guidelines for Patients With ST-Elevation
Myocardial Infarction
Check Blood Pressure
Systolic BP Greater than 100 mm Hg
Systolic BP 70 to 100 mm Hg NO signs/symptoms of
shock
Systolic BP 70 to 100 mm Hg Signs/symptoms of
shock
Systolic BP less than 70 mm Hg Signs/symptoms of
shock
Systolic BP Greater than 100 mm Hg and not less
than 30 mm Hg below baseline
Second line of action
Norepinephrine 0.5 to 30 mcg/min IV
Dobutamine 2 to 20 mcg/kg per minute IV
Nitroglycerin 10 to 20 mcg/min IV
Dopamine 5 to 15 mcg/kg per minute IV
ACE Inhibitors Short-acting agent such as
captopril (1 to 6.25 mg)
Further diagnostic/therapeutic considerations
(should be considered in nonhypovolemic
shock) Diagnostic Therapeutic ? Pulmonary
artery catheter ? Intra-aortic balloon
pump ? Echocardiography ?
Reperfusion/revascularization ? Angiography for
MI/ischemia ? Additional diagnostic studies
Circulation 2000102(suppl I)I-172-I-216.
Third line of action
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All-Cause Mortality
TRACEEchocardiographicEF 35
AIREClinical and/or radiographic signs of HF
SAVERadionuclideEF 40
Probability of Event
Placebo 866/2971 (29.1)
ACE-I 702/2995 (23.4)
OR 0.74 (0.660.83)
Years
ACE-I 2995 2250 1617 892 223
Placebo 2971 2184 1521 853 138
Flather MD, et al. Lancet. 200035515751581
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SHOCK CARDIOGENICOIMA
When NOT to give Nitroglycerin
Nitrates should not be administered to patients
with Nitrates should not be administered
to patients who have received a phosphodiesterase
inhibitor for erectile dysfunction within the
last 24 hours (48 hours for tadalafil).

• systolic pressure lt 90 mm Hg or to 30 mm Hg
  below baseline
• severe bradycardia (lt 50 bpm)
• tachycardia (gt 100 bpm) or
• suspected RV infarction.

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EVIDENCE GRADING
SHOCK CARDIOGENICOIMA
BENEFICIAL HARMFUL
A B C
RANDOMIZED EXPERT OPINION
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PCI for Cardiogenic Shock
Cardiogenic Shock
Early Shock, Diagnosed on Hospital Presentation
Delayed Onset Shock Echocardiogram to Rule Out
Mechanical Defects
Fibrinolytic therapy if all of the following are
present 1. Greater than 90 minutes to
PCI 2. Less than 3 hours post STEMI onset 3. No
contraindications Arrange prompt transfer to
invasive procedure-capable center
Arrange rapid transfer to invasive
procedure-capable center
IABP
Cardiac Catheterization and Coronary Angiography
1-2 vessel CAD
Moderate 3-vessel CAD
Severe 3-vessel CAD
Left main CAD
PCI IRA
PCI IRA
Immediate CABG
Cannot be performed
Staged Multivessel PCI
Staged CABG
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SHOCK CARDIOGENICO
BALON DE CONTRAPULSACION AORTICO (IABP)
CLASE IA

• lt 75 AÑOS
• ST
• BCRI
• SHOCK lt 36 HS DEL IMA
• INTERVENCION lt 18 HORAS
• REVASCULARIZACION TEMPRANA

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SHOCK CARDIOGENICO
BALON INTRAORTICO DE CONTRAPULSACION (IABP)
CLASE IB

• STEMI PAS lt 90 mm Hg
• PAm lt 30 mm Hg

• STEMI ESTADO DE BAJO GASTO CARDIACO
• STEMI SHOCK SIN RESPUESTA FARMACOLOGICA

CLASE IC

• STEMI DOLOR PRECORDIAL
• ISQUEMIA RECURRENTE
• INESTABILIDAD HEMODINAMICA
• FUNCION VENTRICULAR DEPRIMIDA
• AREA MIOCARDICA DE RIESGO GRANDE
• IACB CAT CIRUGIA

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SHOCK CARDIOGENICO
BALON INTARORTICO DE CONTRAPULSACION (IABP)
CLASE II a

• STEMI TAQUICARDIA VENTRICULAR POLIMORFA

• STEMI ICC

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A C P
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SHOCK CARDIOGENICOIMA
ACP PRIMARIA O DE RESCATE EN STEMI

• DEBE REALIZARSE IB-
• en pacientes severa (ICC) (Killip clase 3)
• con Sx lt 12 horas

• La ACP Primaria debe realizarse -IA-
• en pacientes lt 75 años
• con elevación ST o BCRI
• SHOCK lt36 horas post MI,
• ACP realizable ltprimeras 18 horas del shock.
• En pacientes gt75 años -IIa B-

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SHOCK CARDIOGENICOIMA
APC POSTERIOR A FIBRINOLISIS

• APC debe ser realizada en pacientes con
• Evidencia objetiva de IMA recurrente
• Isquemia miocardica moderada o severa, ya sea
  espontanea o provocada, durante la recuperacion
  STEMI
• Shock cardiogenico o inestabilidad hemodinamica.

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FIBRINOLÍSISREPERFUSIÓN
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SHOCK CARDIOGENICO
CLASE I

• FIBRINOLISIS
• CUANDO INTERVENCION ESTA CONTRAINDICADA
• MONITOREO HEMODINAMICO INTRAARTERIAL
• ECOCARDIOGRAFIA
• (EVIDENCIAR COMPLICACIONES MECANICAS)

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SHOCK CARDIOGENICO
REVASCULARIZACION
(P0.11)
(Plt0.03)
THE SHOCK TRIAL
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SHOCK CARDIOGENICO
CLASE II

• REVASCULARIZACION TEMPRANA
• lt 75 AÑOS
• ST
• BCRI
• SHOCK lt 36 HS DEL IMA
• INTERVENCION lt 18 HORAS
• gt 75 AÑOS INDICACION IIaB

• CATETER PULMONAR

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Evidence-Based Approach to Need for
Catheterization and Revascularization After STEMI
STEMI
STEMI
Primary Invasive Strategy
Fibrinolytic Therapy
No Reperfusion Therapy
Primary Invasive Strategy
Fibrinolytic Therapy
No Reperfusion Therapy
Cath
No Cath
Cath
No Cath
EF less
EF greater
EF less
EF greater
Performed
Performed
Performed
Performed
than 0.40
than 0.40
than 0.40
than 0.40
EF greater
EF less
EF greater
EF less
High
-
Risk
No High
-
Risk
High
-
Risk
No High
-
Risk
than 0.40
than 0.40
than 0.40
than 0.40
Features

Features
Features

Features
Catheterization and
Catheterization and
Revascularization as
Revascularization as
No High
-
Risk
High
-
Risk
No High
-
Risk
High
-
Risk
Indicated
Indicated
Features

Features

Features
Features
Revascularization as
Revascularization as
Functional
Functional
Indicated
Indicated
Evaluation
Evaluation
ECG Interpretable
ECG Uninterpretable
ECG Interpretable
ECG Uninterpretable
Unable to Exercise
Unable to Exercise
Able to Exercise
Able to Exercise
Able to Exercise
Able to Exercise
Pharmacological Stress
Pharmacological Stress
Submaximal
Submaximal
Symptom
-
Limited
Symptom
-
Limited
Adenosine
Exercise
Exercise
Exercise
Exercise
Dobutamine
Dobutamine
Exercise Test
Exercise Test
Exercise Test
Exercise Test
or Dipyridamole
Echo
Nuclear
Echo
Nuclear
Echo
Echo
Before Discharge
Before or After Discharge
Before Discharge
Before or After Discharge
Nuclear Scan
Catheterization and
Catheterization and
Clinically Significant
No Clinically Significant
Medical
Clinically Significant
No Clinically Significant
Medical
Revascularization as
Revascularization as
Ischemia
Ischemia
Therapy
Ischemia
Ischemia
Therapy
Indicated
Indicated
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Right Ventricular Infarction
Clinical findingsShock with clear lungs,
elevated JVPKussmaul sign Hemodynamics
Increased RA pressure (y descent)Square root
sign in RV tracing ECGST elevation in R sided
leads EchoDepressed RV function RxMaintain RV
preloadLower RV afterload (PA---PCW)Inotropic
supportReperfusion
V4R
Modified from Wellens. N Engl J Med 1999340381.
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SHOCK CARDIOGENICO
SOSPECHA DE IMA VD STEMI INESTABILIDAD
HEMODINAMICA
INFERIOR
CLASE I

• EKG V4R
• ECOCARDIOGRAMA

• REPERFUSION TEMPRANA ACP
• CORREGIR BRADICARDIA Y ASINCRONIA AV
• PRECARGA DERECHA
• CARGA INICAL RESPUESTA POSITIVA
• OPTIMIZAR VOLUMEN
• PV lt NORMAL

• POSCARGA DERECHA
• OPTIMIZAR FUNCION V IZQ.

• ASISTENCIA INOTROPICA
• CUANDO SOBRECARGA DE VOLUMEN ES INSUFICIENTE

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Ventricular Septal Rupture
Mitral Regurgitation(Pap. M. dysfunction)
Free WallRupture
Incidence 1-2 1-6 1-2Timing 3-5 d p
MI 3-6 d p MI 3-5 d p MIPhy Exam murmur
90 JVD, EMD murmur 50Thrill Common
No RareEcho Shunt Peric.
Effusion Regurg. JetPA cath O2 step up
Diast Press Equal. c-v wave in PCW
ImagesCourtesy of W D Edwards (Mayo
Foundation)Data Lavocitz. CV Rev Rpt
19845948 Birnbaum. NEJM 20023471426.
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SHOCK CARDIOGENICO
REGURGITACION MITRAL

• RUPTURA DE MUSCULO PAPILAR
• CIRUGIA URGENTE

Mitral Regurgitation(Pap. M. dysfunction)

• CONCOMITANTE CABG

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SHOCK CARDIOGENICO
RUPTURA SEPTAL O DE PARED LIBRE
Ventricular Septal Rupture

• CIRUGIA URGENTE

• CABG

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SHOCK CARDIOGENICO
ANEURISMA VENTRICULAR

• STEMI AV ARRITMIA INTRATABLE Y/O SHOCK
• ANEURISMECTOMIA CABC

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ICD Implantation After STEMI
One Month After STEMI No Spontaneous VT or VF
48 hours post-STEMI
EF lt 0.30
EF 0.31 - 0.40

EF gt 0.40
No
Yes
EPS

-
NEJM 349 1836,2003
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• Atacado de fiebres un indio de Loja llamado
  Pedro de Leyva, bebió, para calmar los ardores de
  la sed, del agua de un remanso, en cuyas
  orillas crecían algunos árboles de quina Con su
  descubrimiento vino a Lima y lo comunicó a
  un jesuita, el que, realizando la feliz curación
  de la virreina, prestó a la Humanidad mayor
  servicio que el fraile que inventó la pólvora.
• Mendiburo dice que, al principio, encontró el
  uso de la quina fuerte oposición en Europa, y que
  en Salamanca se sostuvo que caía en pecado mortal
  el médico que la recetaba, pues sus virtudes eran
  debidas a pacto de los peruanos con el diablo.

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PAZ MUNDIAL