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ACC/AHA 2007 STEMI Guidelines Focused Update
UNIVERSIDAD RICARDO PALMAFACULTAD DE MEDICINA HUMANA
V CURSO INTERNACIONAL DE ACTUALIZACIÓN EN MEDICINA Y CIRUGIA – IV JORNADA DE EDUCACIÓN MÉDICA UNIVERSITARIA
CONFERENCIA:
“SHOCK CARDIOGÉNICO”
DOCTORALFREDO PALACIO
I N C A P U E E SINSTITUTO NACIONAL DE CARDIOLOGIA FACULTAD DE MEDICINA “ALFREDO PALACIO” “ENRIQUE ORTEGA MOREIRA”
GUAYAQUIL – ECUADOR
SHOCK CARDIOGENICO
•DEFINICION:•EVIDENCIA CLINICA DE HIPOPERFUSION•CON PRESION ARTERIAL SISTOLICA < 90 mm Hg > 30 min•NECESIDAD DE TERAPIA PARA MANTENER PAS > DE 90 mmHg•IC < 2.2 L/ min / m2•PCP (en cuña) > 15 mm Hg
THE SHOCK TRIAL JAMA 2001; 285: 190-2
SHOCK CARDIOGENICO
PREREPERFUSION REPERFUSION
PREVALENCIA
EN IMA
20% 5 – 7 %
MORTALIDAD 80% 40% *
SOBREVIDA – IH -INTRAHOSPITALARIA + / IABP
20-50%
70 %
* 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
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
SHOCK CARDIOGENICO
• PRIMER RX– LIMITAR TAMAÑO DEL IMA– RESTABLECER REPERFUSION
CORONARIA– CONTROLAR RESPUESTAS
INJURIOSAS» ACTIVIDAD SIMPATICA» SISTEMA SRA» RESISTENCIA PERIFERICA» POST CARGA
SHOCK CARDIOGENICOCURVAS DE PRESION Y DE PERFUSION CORONARIA
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
Emergency Management of Complicated STEMIEmergency Management of Complicated STEMI
Administer• Fluids• Blood transfusions• Cause-specific interventionsConsider vasopressors
Arrhythmia
Bradycardia Tachycardia
Systolic BPGreater than 100 mm Hg
Systolic BP 70 to 100 mm Hg
NO signs/symptomsof shock
Systolic BP70 to 100 mm HgSigns/symptoms
of shock
Systolic BP less than 70 mm Hg
Signs/symptoms of shock
Dobutamine2 to 20
mcg/kg per minute IV
Low Output -Cardiogenic Shock
Nitroglycerin10 to 20 mcg/min IV
Dopamine5 to 15
mcg/kg per minute IV
Norepinephrine0.5 to 30 mcg/min IV
Hypovolemia
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 shockF
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ACC/AHA Guidelines for Patients With ST-Elevation
Myocardial Infarction
Check Blood Pressure
Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edemaMost likely major underlying disturbance?
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
Acute Pulmonary Edema
Check Blood Pressure
Systolic BP Greater than 100 mm Hg
and not less than 30 mm Hg below baseline
ACE InhibitorsShort-acting agent such as
captopril (1 to 6.25 mg)
Circulation 2000;102(suppl I):I-172-I-216.
All-Cause Mortality
Years
Pro
bab
ilit
y o
f Even
t
0
0.05
0.1
0.15
0.2
0.25
0.3
0 1 2 3
0.35
0.4
4
ACE-I
Placebo
ACE-I 2995 2250 1617 892 223
Placebo 2971 2184 1521 853 138
Flather MD, et al. Lancet. 2000;355:1575–1581
OR: 0.74 (0.66–0.83)OR: 0.74 (0.66–0.83)
ACE-I: 702/2995 (23.4%)ACE-I: 702/2995 (23.4%)
Placebo: 866/2971 (29.1%)Placebo: 866/2971 (29.1%)
TRACEEchocardiographicEF 35%
AIREClinical and/or radiographic signs of HF
SAVERadionuclideEF 40%
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 < 90 mm Hg or ≥ to 30 mm Hg below baseline
• severe bradycardia (< 50 bpm)• tachycardia (> 100 bpm) or• suspected RV infarction.
When NOT to give NitroglycerinWhen NOT to give Nitroglycerin
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
SHOCK CARDIOGENICOIMA
EVIDENCE GRADING
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
A B CBENEFICIAL HARMFULBENEFICIAL HARMFUL
RANDOMIZED EXPERT OPINION
SHOCK CARDIOGENICOIMA
Cardiogenic Shock
1-2 vessel CAD Moderate 3-vessel CAD Severe 3-vessel CAD Left main CAD
PCI IRA PCI IRA Immediate CABG
Staged Multivessel PCI
Staged CABGCannot be performed
Early Shock, Diagnosed on Hospital Presentation
Delayed Onset Shock Echocardiogram to Rule Out
Mechanical Defects
Cardiac Catheterization and Coronary Angiography
IABP
Fibrinolytic therapy if all of the following are present:
1. Greater than 90 minutes to PCI2. Less than 3 hours post STEMI
onset3. No contraindications
Arrange prompt transfer to invasive procedure-capable center
Arrange rapid transfer to invasive procedure-capable center
PCI for Cardiogenic ShockPCI for Cardiogenic Shock
SHOCK CARDIOGENICO
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
< 75 AÑOS• ST • BCRI• SHOCK < 36 HS DEL IMA• INTERVENCION < 18 HORAS
REVASCULARIZACION TEMPRANA
CLASE IA
BALON DE CONTRAPULSACION AORTICO (IABP)
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ACC/AHA 2007 STEMI Guidelines Focused Update
SHOCK CARDIOGENICO
STEMI + PAS < 90 mm HgPAm < 30 mm Hg
CLASE IB
BALON INTRAORTICO DE CONTRAPULSACION (IABP)
STEMI + ESTADO DE BAJO GASTO CARDIACO STEMI + SHOCK SIN RESPUESTA FARMACOLOGICA
STEMI + DOLOR PRECORDIAL ISQUEMIA RECURRENTE INESTABILIDAD HEMODINAMICA FUNCION VENTRICULAR DEPRIMIDA AREA MIOCARDICA DE RIESGO GRANDEIACB + CAT + CIRUGIA
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
CLASE IC
SHOCK CARDIOGENICO
STEMI + TAQUICARDIA VENTRICULAR POLIMORFA
CLASE II a
BALON INTARORTICO DE CONTRAPULSACION (IABP)
STEMI + ICC
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
ACC/AHA 2007 STEMI Guidelines Focused Update
A C P
ACP PRIMARIA O DE RESCATE EN STEMI:ACP PRIMARIA O DE RESCATE EN STEMI:
DEBE REALIZARSE –IB-
•en pacientes severa (ICC) (Killip clase 3)
• con Sx < 12 horas
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
La ACP Primaria debe realizarse -IA- • en pacientes < 75 años •con elevación ST o BCRI • SHOCK <36 horas post MI, • ACP realizable <primeras 18 horas del shock.En pacientes >75 años: -IIa B-
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
SHOCK CARDIOGENICOIMA
APC POSTERIOR A FIBRINOLISISAPC 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.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
SHOCK CARDIOGENICOIMA
ACC/AHA 2007 STEMI Guidelines Focused Update
FIBRINOLÍSISREPERFUSIÓN
SHOCK CARDIOGENICO
FIBRINOLISIS–CUANDO INTERVENCION ESTA CONTRAINDICADA
MONITOREO HEMODINAMICO INTRAARTERIAL
ECOCARDIOGRAFIA–(EVIDENCIAR COMPLICACIONES MECANICAS)
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
CLASE I
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ACC/AHA 2007 STEMI Guidelines Focused Update
SHOCK CARDIOGENICO
REVASCULARIZACION DE EMERGENCIA
ESTABILIZACION MEDICA INICAL
MORTALIDAD 30 DIAS
46.7% 50.0%
6 A 12 MESES 53.3% 66.4%
THE SHOCK TRIAL
(P=0.11)
(P<0.03)
REVASCULARIZACION
SHOCK CARDIOGENICO
CATETER PULMONAR
REVASCULARIZACION TEMPRANA• < 75 AÑOS• ST • BCRI• SHOCK < 36 HS DEL IMA• INTERVENCION < 18 HORAS• > 75 AÑOS INDICACION IIaB
CLASE II
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Right Ventricular InfarctionClinical findings:
Shock with clear lungs, elevated JVPKussmaul sign
Hemodynamics: Increased RA pressure (y descent)Square root sign in RV tracing
ECG:ST elevation in R sided leads
Echo:Depressed RV function
Rx:Maintain RV preloadLower RV afterload (PA---PCW)Inotropic supportReperfusion
V4R
Modified from Wellens. N Engl J Med 1999;340:381.
SHOCK CARDIOGENICO
EKG + V4R ECOCARDIOGRAMA
CLASE I
SOSPECHA DE IMA VD STEMI + INESTABILIDAD HEMODINAMICAINFERIOR
REPERFUSION TEMPRANA ACP CORREGIR BRADICARDIA Y ASINCRONIA AV PRECARGA DERECHA
CARGA INICAL RESPUESTA POSITIVAOPTIMIZAR VOLUMENPV < NORMAL
POSCARGA DERECHA OPTIMIZAR FUNCION V IZQ.
ASISTENCIA INOTROPICACUANDO SOBRECARGA DE VOLUMEN ES
INSUFICIENTE
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Ventricular Septal Rupture
Mitral Regurgitation(Pap. M. dysfunction)
Incidence 1-2% 1-6% 1-2%Timing 3-5 d p MI 3-6 d p MI 3-5 d p MIPhy Exam murmur 90% JVD, EMD murmur 50%Thrill Common No RareEcho Shunt Peric. Effusion Regurg. JetPA cath O2 step up Diast Press Equal. c-v wave in PCW
Images:Courtesy of W D Edwards (Mayo Foundation)Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426.
Free WallRupture
SHOCK CARDIOGENICO
RUPTURA DE MUSCULO PAPILARCIRUGIA URGENTE
REGURGITACION MITRAL
CONCOMITANTE CABG
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Mitral Regurgitation(Pap. M. dysfunction)
SHOCK CARDIOGENICO
CIRUGIA URGENTE
RUPTURA SEPTAL O DE PARED LIBRE
CABG
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIVentricular
Septal Rupture
SHOCK CARDIOGENICO
STEMI + AV + ARRITMIA INTRATABLE Y/O SHOCKANEURISMECTOMIA + CABC
ANEURISMA VENTRICULAR
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
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ACC/AHA 2007 STEMI Guidelines Focused Update
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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ACC/AHA 2007 STEMI Guidelines Focused Update
PAZ MUNDIAL