Alessandro SionisUnitat de Cures Agudes Cardiològiques

Hospital de la Santa Creu i Sant PauUniversitat Autònoma de Barcelona

1

Codi Shock: Situació Actual al Nostre Entorn

Disclosures (last 5 years)

► Speaker: Abiomed, Astra-Zeneca, Bayer, Boheringher, Ferrer, Getinge-Maquet, Novartis, Orion-Pharma, Sanofi, Servier, Singulex

► Clinical trials: Bristol-Myers Squibb, Cardiorentis, DalCor, Esperion, Ferrer,Janssen, Novartis, Orion-Pharma, Singulex, Zoll

► Research grants: Novartis, Orion-Pharma, Singulex

► Royalties: No

Current In-hospital MortalityUSIK 1995, USIC 2000, FAST-MI France National Registry and CardShock

Modified from Aissaoui et al. Eur Heart J 2012;33:2535

Dea

that

30 d

ays(

%)

70

63

51

44

8,74,2 3,6 3,4

0

10

20

30

40

50

60

70

80

1995 2000 2005 2012

Shock No Shock

Delays in pPCI and in Patients With CS

Kochar A et al. J Am Coll Cardiol Intv 2018;11:1824–33

23,785 STEMI patients from 2012 to 2014 (8.4% had CS)

Delays in pPCI and in Patients With CS

Kochar A et al. J Am Coll Cardiol Intv 2018;11:1824–33

23,785 STEMI patients from 2012 to 2014 (8.4% had CS)

Factors Associated With Mortality for Direct-Presenting CS Patients Factors Associated With Mortality for TrasnferredCS Patients

Impact of STEMI Treatment Delay (FITT-STEMI Trial)

Scholz KH et al. European Heart Journal (2018) 0, 1–10

12,675 STEMI patients

3.31 additional deaths for 100 pPCI

Cardiogenic Shock: Etiology

LVRV

Pericardial

Valvular

Arrhythmias

Aortic dissection

Cardiomyopathies

Pulmonary embolism

Pneumothorax

Myocarditis

STEMI

NSTEMI

Mechanical complications

Cardiogenic Shock in Catalonia 2008-2016

Courtesy of: Pla Director Malalties Cardiovasculars (CatSalut; AQuAS)

An MBDS Analysis of 7,944 hospitalizations (ICD: 785.51)

768719

796 791

912952

919966

923

0

200

400

600

800

1000

1200

2008 2009 2010 2011 2012 2013 2014 2015 2016

20% increase from 2008 to 2016Mortality 55.6 % (from 64.8% to 48.3%)

Cardiogenic Shock in Catalonia 2008-2016

Courtesy of: Pla Director Malalties Cardiovasculars (CatSalut; AQuAS)

An MBDS Analysis of 7,944 hospitalizations (ICD: 785.51)

All MCS No-MCS p

Age (mean; SD) 72.41 (13.4) 64.61 (13.41) 73.54 (13.02) <0.01

Women (%) 38.5 28.9 39.9 <0.01

CAD (%) 50-0 77.4 46.0 <0.01

pPCI (%) 21.0 55.2 16.2 <0.01

CABG (%) 2.8 11.1 1.7 <0.01

Mechanical ventilation (%) 34.9 46.1 33.3 <0.01

CKD (%) 18.7 11.7 11.7 <0.01

Atrial Fibrillation (%) 27.3 17.2 28.7 <0.01

Diabetes (%) 24.9 20.0 25.6 <0.01

PAD (%) 5.2 3.8 5.4 <0.01

Characteristics of Patients Requiring Mechanical Circulatory Support (MCS)

Cardiogenic Shock in Catalonia 2008-2016

Courtesy of: Pla Director Malalties Cardiovasculars (CatSalut; AQuAS)

An MBDS Analysis of 7,944 hospitalizations (ICD: 785.51)

All MCS No-MCS p

IAM-SEST (N; %) 1.167 (15.1%) 162 (16) 1005 (14.8) 0.144

IAM-EST (N; %) 2.118 (27.3) 506 (52) 1612 (23.8) <0.01

Miocarditis (N; %) 88 (1.1) 29 (3.0) 59 (0.9) <0.01

Pulmonary embolism 255 (3.3) 9 (0.7) 246 (3.6) <0.01

Other 4.118 (53.2) 268 (3.4) 3.850 (49.7) <0.01

Patients Requiring Mechanical Circulatory Support (MCS): 974 / 7.746 (12.57%)

Cardiogenic Shock in Catalonia: Use of MCS 2008-2016

Courtesy of: Pla Director Malalties Cardiovasculars (CatSalut; AQuAS)

An MBDS Analysis of 7,944 hospitalizations (ICD: 785.51)

68

55

9892

113

132 134

144138

0

20

40

60

80

100

120

140

160

2008 2009 2010 2011 2012 2013 2014 2015 2016

120% increase from 2008 to 2016

• Pre-Cardiogenic shock

• CS Grade I (mild)

• CS Grade II (profound)

• CS Grade III (advanced)

Different Phenotypes of Cardiogenic Shock

• Mortality?

• Need for catecholamines

• Need for MCS

• Futility?

One Size Does Not Fit All: CS Severity Classification

80%

42%

21%

7.5%3%

Mortality Risk vs Inotrope Dosing

Pre-Shock Mild Shock Profound Shock Refractory Shock

Conv

entio

nal

Devi

ces

Low dose Moderate dose One high-dose Two high-dose Three high-dose

Adapted from: Biswajit Kar at al. Circulation. 2012;125:1809-1817

CS May Not Be Easy to Diagnose In Early Stages

80%

42%

21%

7.5%3%

Mortality Risk vs Inotrope Dosing

Pre-Shock Mild Shock Profound Shock Refractory Shock

Conv

entio

nal

Devi

ces

Low dose Moderate dose One high-dose Two high-dose Three high-dose

Adapted from: Biswajit Kar. Circulation. 2012;125:1809-1817

? ?

Definition of Pre-Shock

Signs of pre-shock or low-flow state. Any of the following unexplained findings in

a patient clinically suspected of being at risk for developing shock:

A. Fall in urine output

B. Rise in heart rate

C. Fall in systolic blood pressure

D. Fall in skin temperature

• Systolic BP<90 mm Hg for 30 minutes or low dose inotrope/vasopressor required to

maintain systolic BP>90 mm Hg

• Pulmonary congestion or elevated LV filling pressure

• Signs of impaired organ perfusion with at least one of the following:

altered mental status

cold clammy skin

oliguria

high lactate (> 2mmol/L)

Cardiogenic Shock Grade I (Mild) Criteria

• Criteria for Cardiogenic shock AND

CI < 2.2 l/min/m OR

lactate > 4 mmol/L

• Despite at least 2 inotropes/vasopressors

Cardiogenic Shock Grade II (Profound) Criteria

• Criteria for advanced cardiogenic shock

• AND two of the following criteria:

lactate > 8 mmol/L

anuria

respiratory failure (NIMV or IMV)

overt RHF

escalating inotropes/vasopressors

Cardiogenic Shock Grade III (Advanced) Criteria

Cardiogenic Shock and Cardiac Arrest ArrestRate of OHCA in Cardiogenic Shock Patients (IABP-SHOCK; CARDSHOCK; CULPRIT-SHOCK)

45,1

28

53,5

0

10

20

30

40

50

60

IABP-SHOCK II CARDSHOCK CULPRIT-SHOCK

Cardiogenic Shock Network: Hub and Spoke Model

Van Diepen S et al. Circulation. 2017;136:e

0

20

40

60

80

100

1 2 3

Ove

rall

surv

ival

(%)

4Time from ECMO implantation (Years)

Cardiac RESCUE

Beurtheret et al. Eur Heart J 2013;34:112

ECMO for Transfer From Non-tertiary Centres (2005-2009)

86% stabilized and transferred

37% discharged alive

Cardiogenic Shock Network: How To Do It

Level 3

Level 2

Level 1

Hub & Spoke Network Model

• Advanced MCS• Heart transplant program

• 24/7 Cath Lab• Short term MCS• ECMO?

• Triage• Initial stabilization• Transfer

Hub

Subh

ubSp

oke

Pre-hospital (Level 0)

Adapted from: Tchantchaleishvili V et al. JAMA Surgery 2015;150: 1025–6

Level 3: Dedicated CS Centers

• Tertiary care centers

• Cardiac catheterization and angioplasty facilities available 24/7

• Advanced MCS and heart transplant options

• On-site cardiothoracic surgery capability

• Established protocol for out-of-hospital cardiac arrest (OHCA)

• A multidisciplinary “cardiogenic shock team”: interventional cardiologist, critical care specialist,

cardiothoracic surgeon, and advanced heart failure specialist

Adapted from: Rab T. et al. J Am Coll Cardiol. 2018;72(16):1972–80

Level 2: STEMI Centers

• Usually tertiary care centers

• Cardiac catheterization and angioplasty facilities available 24/7

• Short-term MCS (Impella®, IABP, ECMO?)

• Usually on-site cardiothoracic surgery capability

• Established protocol for out-of-hospital cardiac arrest (OHCA)

• Clear pathway for Level 3 center referral

Adapted from: Rab T. et al. J Am Coll Cardiol. 2018;72(16):1972–80

Level 1: Community Hospitals

• Usually Community Hospitals

• No on-site cardiac catheterization facilities available 24/7

• No MCS capability

• No on-site cardiothoracic surgery capability

• CS patients should be directly transferred to Level 3 centers

Adapted from: Rab T. et al. J Am Coll Cardiol. 2018;72(16):1972–80

29

Risk Stratification: CardShock Score

Harjola V-P et al. Eur J Heart Fail 2015;17:501-509

EURO-ELSO Registry: SAVE Score

Schmidt M et al. Eur Heart J. 2015;36:2246–56.

AUC 0.68 (95% CI 0.64-0.71)

www.santpau.orgasionis@santpau.cat