1 UNIVERSIDAD RICARDO PALMA FACULTAD DE MEDICINA HUMANAV 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
2 SHOCK CARDIOGENICO DEFINICION: EVIDENCIA CLINICA DE HIPOPERFUSIONCON 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
3 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: NEJM 1991; 325: JACC 1992; 20:
4 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
5 SHOCK CARDIOGENICO PRIMER RX LIMITAR TAMAÑO DEL IMARESTABLECER REPERFUSION CORONARIA CONTROLAR RESPUESTAS INJURIOSAS ACTIVIDAD SIMPATICA SISTEMA SRA RESISTENCIA PERIFERICA POST CARGA EL PRIMER PASO AL MANEJO DE SHOCK CARDIOGENO ES SU PREVENCIÓN MEDIANTE LA LIMITACIÓN DEL TAMAÑO DEL IMA, RESTABLECER LA PERFUSIÓN CORONARIA Y CONTROLANDO LAS RESPUESTAS INJURIOSAS
6 CURVAS DE PRESION Y DE PERFUSION CORONARIASHOCK CARDIOGENICO CURVAS DE PRESION Y DE PERFUSION CORONARIA La perfusión coronaria ocurre el momento de máximo volumen de VI y de mínima resistencia del mismo. Las 2 Presiones coronarias y generan perfusión contra la baja resistencia Diastólica En sistole las presiones de A– y VI se igualan el VI se contrae no hay perfusión + volumen VI. Si la presión coronaria cae bajo la Presión aórtica, el flujo se mantiene por auto refulación. Luego ISQUEMIA = CONTRACTILIDAD PFVI Bajo Gas—o SHOCK P P ISQUEMIA
7 SHOCK CARDIOGENICO IMAInjuria Miocardica Irreversible min Injuria completa area de riesgo Hrs Mayor magnitud del daño Hrs Restauración del flujo para obtener mayor beneficio Hrs Hipóteis de arteria abierta flujo normal mortalidad Tamaño de infarto lo anterior mas colaterales
8 Most likely major underlying disturbance?Emergency Management of Complicated STEMI Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema Most likely major underlying disturbance? Hypovolemia Low Output - Cardiogenic Shock Arrhythmia 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 Administer Fluids Blood transfusions Cause-specific interventions Consider vasopressors Bradycardia Tachycardia 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 Nitroglycerin 10 to 20 mcg/min IV Dobutamine 2 to 20 mcg/kg per minute IV Dopamine 5 to 15 mcg/kg per minute IV Norepinephrine 0.5 to 30 mcg/min IV ACE Inhibitors Short-acting agent such as captopril (1 to 6.25 mg) The emergency management of patients with cardiogenic shock (CS), acute pulmonary edema (PE) or both is outlined. Las complicaciones que demandan emergencias ee el IMA mas comunmente son Edema Pulmonar Agudo, Hipovolemia, Shoc Cadiógeno y Arritmias: Si la PAS está 70 a 100 mm Hg, Pero sin Sx ni Sg de ShocK: Dobutamina 2 a 20 mcg/kg/min IV. Si la PAS esta <70 a 100 mm Hg con Sx y Sx de Shock: Dopamine 5 a 18 mcg/Kg/min IV Si la PAS esta <70 mm Hg: Norepinefrina 5 a 30 mcg/Kg/min IV. Si la PAS >100mm Hg: NTG. Si la PAS >100 mmHg ( y hasta 30 mmhg de la PA basal): Inhibidores e la ECA. El siguiente paso medidas DX y RX 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 2000;102(suppl I):I-172-I-216. Third line of action
9 All-Cause Mortality SAVE Radionuclide EF £ 40%AIRE Clinical and/or radiographic signs of HF TRACE Echocardiographic EF £ 35% All-Cause Mortality 0.05 0.1 0.15 0.2 0.25 0.3 1 2 3 0.35 0.4 4 Placebo Probability of Event ACE-I Placebo: 866/2971 (29.1%) ACE-I: 702/2995 (23.4%) OR: 0.74 (0.66–0.83) Desde e Etudio SOLVD con el Enalapril se ha prbado que los inhibidores de la ECA mejoran mortalidad en presencia de bajo gasto o ICC. Lo confirman el SAVE, el AIRE, el TRACE. Years ACE-I Placebo Flather MD, et al. Lancet. 2000;355:1575–1581
10 SHOCK CARDIOGENICO IMA When NOT to give NitroglycerinNitrates 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.
11 SHOCK CARDIOGENICO IMAEVIDENCE GRADING Seguimos el mismo abordaje Probabilístico de 4 CLASES de INDICACIONES de lo Beneficioso a lo Perjudicial con 3 niveles de Evidencia. BENEFICIAL HARMFUL A B C RANDOMIZED EXPERT OPINION
12 PCI for Cardiogenic ShockEarly 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 Pacientes e Shock Cardíogenico de Presentación Temprana o TARDIA IABP ANYLA REN---LIZA Ahora, en la Presentación Temprana ----- FIBRINOLISIS, si es que >90¨ ( sin APC ) < 3 HORAS del IMA 1 – 2 Vasos vasos Modea vasos o tienen A P C ARI Otros Vasos Cannot be performed Staged Multivessel PCI Staged CABG
13 SHOCK CARDIOGENICO A CLASE IA BALON DE CONTRAPULSACION AORTICO (IABP)IIa IIb III A < 75 AÑOS ST BCRI SHOCK < 36 HS DEL IMA INTERVENCION < 18 HORAS REVASCULARIZACION TEMPRANA
14 BALON INTRAORTICO DE CONTRAPULSACION (IABP)SHOCK CARDIOGENICO BALON INTRAORTICO DE CONTRAPULSACION (IABP) CLASE IB I IIa IIb III B STEMI + PAS < 90 mm Hg PAm < 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
15 BALON INTARORTICO DE CONTRAPULSACION (IABP)SHOCK CARDIOGENICO BALON INTARORTICO DE CONTRAPULSACION (IABP) CLASE II a STEMI + TAQUICARDIA VENTRICULAR POLIMORFA STEMI + ICC
16 A C P
17 SHOCK CARDIOGENICO IMA ACP PRIMARIA O DE RESCATE EN STEMI:DEBE REALIZARSE –IB- en pacientes severa (ICC) (Killip clase 3) con Sx < 12 horas La ACP Primaria debe realizarse -IA- en pacientes < 75 años con elevación ST o BCRI SHOCK <36 horas post MI, ACP realizable
18 SHOCK CARDIOGENICO IMA APC POSTERIOR A FIBRINOLISISAPC 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.
19 FIBRINOLÍSIS REPERFUSIÓN
20 SHOCK CARDIOGENICO B FIBRINOLISIS CLASE IIIa IIb III B FIBRINOLISIS CUANDO INTERVENCION ESTA CONTRAINDICADA MONITOREO HEMODINAMICO INTRAARTERIAL ECOCARDIOGRAFIA (EVIDENCIAR COMPLICACIONES MECANICAS)
21 SHOCK CARDIOGENICO REVASCULARIZACION REVASCULARIZACION DE EMERGENCIAESTABILIZACION MEDICA INICAL MORTALIDAD 30 DIAS 46.7% 50.0% 6 A 12 MESES 53.3% 66.4% (P=0.11) (P<0.03) THE SHOCK TRIAL
22 SHOCK CARDIOGENICO A CLASE II < 75 AÑOS ST BCRIIIb III A REVASCULARIZACION TEMPRANA < 75 AÑOS ST BCRI SHOCK < 36 HS DEL IMA INTERVENCION < 18 HORAS > 75 AÑOS INDICACION IIaB CATETER PULMONAR
23 Evidence-Based Approach to Need for Catheterization and Revascularization After STEMI STEMI STEMI Primary Invasive Strategy Primary Invasive Strategy Fibrinolytic Therapy Fibrinolytic Therapy No Reperfusion Therapy No Reperfusion Therapy Cath Cath No Cath No Cath EF less EF less EF greater EF greater Performed Performed Performed Performed than 0.40 than 0.40 than 0.40 than 0.40 EF greater EF greater EF less EF less High High - - Risk Risk No High No High - - Risk 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 No High - - Risk Risk High High - - Risk Risk Indicated Indicated Features Features † Features Features † Revascularization as Revascularization as Functional Functional Indicated Indicated Evaluation Evaluation ECG Interpretable ECG Interpretable ECG Uninterpretable ECG Uninterpretable Able to Exercise Able to Exercise Unable to Exercise Unable to Exercise Able to Exercise Able to Exercise Pharmacological Stress Pharmacological Stress This algorithm shows the treatment paths for patients who initially undergo a primary invasive strategy, receive fibrinolytic therapy, or do not undergo reperfusion therapy for STEMI. Patients who have not undergone a primary invasive strategy and have no high risk features should undergo functional evaluation using one of the noninvasive tests shown. When clinically significant ischemia is detected, patients should undergo catheterization and revascularization as indicated; if no clinically significant ischemia is detected, medical therapy is prescribed post-STEMI. Submaximal Submaximal Symptom Symptom - - Limited Limited Adenosine Exercise Test Exercise Test Exercise Test Exercise Test Dobutamine Dobutamine Exercise Exercise Exercise Exercise or Dipyridamole Before Discharge Before Discharge Echo Echo Nuclear Nuclear Before or After Discharge Before or After Discharge Nuclear Scan Echo Echo Catheterization and Catheterization and Clinically Significant Clinically Significant No Clinically Significant No Clinically Significant Medical Medical Revascularization as Revascularization as Ischemia Ischemia* Ischemia* Ischemia Therapy Therapy Indicated Indicated
24 Right Ventricular InfarctionClinical findings: Shock with clear lungs, elevated JVP Kussmaul 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 preload Lower RV afterload (PA---PCW) Inotropic support Reperfusion V4R Modified from Wellens. N Engl J Med 1999;340:381.
25 SOSPECHA DE IMA VD STEMI + INESTABILIDAD HEMODINAMICASHOCK CARDIOGENICO SOSPECHA DE IMA VD STEMI + INESTABILIDAD HEMODINAMICA INFERIOR CLASE I I IIa IIb III B EKG + V4R ECOCARDIOGRAMA REPERFUSION TEMPRANA ACP CORREGIR BRADICARDIA Y ASINCRONIA AV PRECARGA DERECHA CARGA INICAL RESPUESTA POSITIVA OPTIMIZAR VOLUMEN PV < NORMAL POSCARGA DERECHA OPTIMIZAR FUNCION V IZQ. ASISTENCIA INOTROPICA CUANDO SOBRECARGA DE VOLUMEN ES INSUFICIENTE
26 Ventricular Septal RuptureMitral Regurgitation (Pap. M. dysfunction) Ventricular Septal Rupture Free Wall Rupture Incidence 1-2% % 1-2% Timing 3-5 d p MI d p MI 3-5 d p MI Phy Exam murmur 90% JVD, EMD murmur 50% Thrill Common No Rare Echo Shunt Peric. Effusion Regurg. Jet PA 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.
27 Mitral Regurgitation (Pap. M. dysfunction)SHOCK CARDIOGENICO REGURGITACION MITRAL I IIa IIb III B RUPTURA DE MUSCULO PAPILAR CIRUGIA URGENTE Mitral Regurgitation (Pap. M. dysfunction) CONCOMITANTE CABG
28 RUPTURA SEPTAL O DE PARED LIBRE Ventricular Septal RuptureSHOCK CARDIOGENICO RUPTURA SEPTAL O DE PARED LIBRE I IIa IIb III B Ventricular Septal Rupture CIRUGIA URGENTE CABG
29 ANEURISMA VENTRICULARSHOCK CARDIOGENICO ANEURISMA VENTRICULAR I IIa IIb III B STEMI + AV + ARRITMIA INTRATABLE Y/O SHOCK ANEURISMECTOMIA + CABC
30 ICD Implantation After STEMIOne Month After STEMI; No Spontaneous VT or VF 48 hours post-STEMI EF < 0.30 EF EF > 0.40 Additional Marker of Electrical Instability? Yes No No ICD. Medical Rx Algorithm to aid in selection of implantable cardioverter/defibrillator (ICD) in patients with STEMI and diminished ejection fraction (EF). The appropriate management path is selected based upon left ventricular ejection fraction (LVEF) measured at least one month after STEMI. These criteria, that are based on the published data, form the basis for the full-text guidelines in section All patients, whether an ICD is implanted or not, should receive medical therapy as outlined in the full-text guidelines. EPS + - NEJM 349: 1836,2003
31 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.
32 PAZ MUNDIAL