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Nick Tehrani, MD
(v.s. 3% in Pts. without shock)
SHOCK registry findings on this point…
The SHOCK registry
Effect of Hypotension (continued…)
Normal heart extracts 65% of the O2 present in the blood
Little room for augmentation of O2 extraction
Elevated LVEDPon coronary flow
Hypotension + LVEDP and critical stenosis
Myocardial Hypoperfusion LV dysfunction Systemic lactic acidosis Impairment of non-ischemic myocardium worsening hypotension.
Williams, et.al., Circulation 1982
Thusballoon pumping increased flow to a bed fed by thecritical stenosis, or collateral vessels
IABP Plus IV NTG
O2, MSo4, Lido,
-Thalium defect score comparing days 1 and 4
-The ejection fraction comparing days 1 and 4
=> “Unlikely that a mortality benefit is conferredby the IABP/NTG combination”
All this, however, does not add up
to improved survival
without Flow Restoration
Than in non-shock pts
Diffusion of thrombolytic agentinto the thrombus may be PRESSURE DEPENDENT.
JACC 1994; 23:784
=> No Benefit
IABP in 62 of the 310 lytic
Rx’d Pts. in shock
Two retrospective observational series from community hospitals:
Improved survival from combination Rx.
Observational Data from SHOCK Registery:
-National Registry of MI-2, Data base-21,178 pts. Presenting with or developing post-MI shock
-32% Received IABP
pts., twice as
likely to get TT
=> Selection Bias
Accompanying Editorial by Magnus Ohman, and Judith Hochman:
“Although, there is a wealth of physiologic and outcomes data to support the use of early IABP therapy in cardiogenic shock (in conjunction with lytics), randomized trials are clearly needed….”
The onlyrandomized trial on the subject:
Thrombolysis and Counterpusion to Improve Cardiogenic Shock Survival (TACTICS): Results of a Prospective Randomized Trial.
Magnus Ohman, et.al.,
Circulation Oct. 2000 Supp. Abstract
For KILLIP classes III and IV, P=0.07
If EARLY REVASCULARIZATION
is not to be pursued:
Administration of Lytics should not be delayed
in anticipation of placement of IABP
despite lack of randomized data proving efficay.
May increase the efficacy of Lytics
EARLY REVASCULARIZATIONimproves survival amongpatients with cardiogenic shock?
302 Pts. with ST elevation
(or new LBBB) and
Late revascularization (if indicated)
deferred for at least 54 hours
30 days mortality
Hassade, et.al., JACC, 2000
Long-Term Mortality Benefit With the Combination of Stents and Abciximab for Cardiogenic Shock Complicating Acute Myocardial Infarction
[Coronary Artery Disease]
Chan, Albert W. MD, MS; Chew, Derek P. MBBS; Bhatt, Deepak L. MD; Moliterno, David J. MD; Topol, Eric J. MD; Ellis, Stephen G. MD
AJC Jan. 15, 2002
96 Pt.s w/
Stent + Reopro
On Univariate analysis:
Absence of Stent use:
HR 2.39, 95% CI 1.22 to 4.67, p = 0.01
Thirty day Mortality Rates (%)
Absence of Abciximab use:
HR 1.95, 95% CI 1.03 to 3.71, p = 0.04
HR 3.44, 95% CI 1.35 to 8.78, p = 0.01
At 30 months
Results of Primary Percutaneous Transluminal Coronary Angioplasty Plus Abciximab With or Without Stenting for Acute Myocardial Infarction Complicated by Cardiogenic Shock[Coronary Artery Disease]Giri, Satyendra MD, MPH, MRCP; Mitchel, Joseph DO; Azar, Rabih R. MD, MSc; Kiernan, Francis J. MD; Fram, Daniel B. MD; McKay, Raymond G. MD; Mennett, Roger MSc; Clive, Jonathan PhD; Hirst, Jeffrey A. MD, MS
AJC, 15 January 2002
Greater use of Abxicimab, and Stents in the SHOCK Trial may well have resulted in a positive primary endpoint.
The age cutoff of 75 may or may not have retained its significance vis-à-vis increased mortality.