UNIVERSIDAD RICARDO PALMA
FACULTAD DE MEDICINA HUMANA
V CURSO INTERNACIONAL DE ACTUALIZACIÓN EN MEDICINA Y CIRUGIA –
IV JORNADA DE EDUCACIÓN MÉDICA UNIVERSITARIA
CONFERENCIA:
“SHOCK CARDIOGÉNICO”
DOCTOR
ALFREDO PALACIO
INCAP
INSTITUTO NACIONAL DE CARDIOLOGIA
“ALFREDO PALACIO”
UEES
FACULTAD DE MEDICINA
“ENRIQUE ORTEGA MOREIRA”
GUAYAQUIL – ECUADOR
ACC/AHA 2007 STEMI Guidelines Focused Update
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% *
+ / IABP
20-50%
70 %
SOBREVIDA – IH INTRAHOSPITALARIA
* 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 CARDIOGENICO
CURVAS DE PRESION Y DE PERFUSION CORONARIA
SHOCK CARDIOGENICO
IMA
•
•
•
•
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 STEMI
Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema
Most likely major underlying disturbance?
Hypovolemia
Third line of
action
Second line of action
First line of action
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
Check Blood Pressure
Systolic BP
Greater than 100 mm Hg
and not less than 30 mm Hg
below baseline
Low Output Cardiogenic Shock
Administer
• Fluids
• Blood transfusions
• Cause-specific
interventions
Consider vasopressors
Arrhythmia
Bradycardia
Tachycardia
Check Blood Pressure
ACC/AHA Guidelines for
Patients With ST-Elevation
Myocardial Infarction
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
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)
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.
SAVE
AIRE
Radionuclide
EF  40%
Clinical and/or
radiographic
signs of HF
Echocardiographic
EF  35%
All-Cause Mortality
0.4
Probability of Event
TRACE
0.35
0.3
0.25
Placebo
0.2
ACE-I
Placebo: 866/2971 (29.1%)
0.15
ACE-I: 702/2995 (23.4%)
0.
1
0.05
0
Years
OR: 0.74 (0.66–0.83)
0
1
2
4
3
ACE-I
2995
2250
1617
892
223
Placebo
2971
2184
1521
853
138
Flather MD, et al. Lancet. 2000;355:1575–1581
SHOCK CARDIOGENICO
IMA
When NOT to give Nitroglycerin
Nitrates should not be administered to patients with:
I IIa IIb III
I IIa IIb III
• systolic pressure < 90 mm Hg or ≥ to 30 mm Hg
below baseline
• severe bradycardia (< 50 bpm)
• tachycardia (> 100 bpm) or
• suspected RV infarction.
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).
SHOCK CARDIOGENICO
IMA
EVIDENCE GRADING
I IIa IIb III
BENEFICIAL
HARMFUL
A B C
RANDOMIZED
EXPERT OPINION
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:
Arrange prompt transfer to invasive
procedure-capable center
Arrange rapid transfer to invasive
procedure-capable center
IABP
1. Greater than 90 minutes to PCI
2. Less than 3 hours post STEMI
onset
3. No contraindications
Cardiac Catheterization and Coronary
Angiography
1-2 vessel CAD
Moderate 3-vessel CAD
PCI IRA
PCI IRA
Staged Multivessel
PCI
Severe 3-vessel CAD
Left main CAD
Immediate CABG
Staged CABG
Cannot be
performed
SHOCK CARDIOGENICO
BALON DE CONTRAPULSACION AORTICO (IABP)
CLASE IA
I IIa IIb III
< 75 AÑOS
• ST
• BCRI
• SHOCK < 36 HS DEL IMA
• INTERVENCION < 18 HORAS
REVASCULARIZACION TEMPRANA
SHOCK CARDIOGENICO
BALON INTRAORTICO DE CONTRAPULSACION (IABP)
CLASE IB
I IIa IIb III
STEMI + PAS < 90 mm Hg
PAm < 30 mm Hg
STEMI + ESTADO DE BAJO GASTO CARDIACO
STEMI + SHOCK SIN RESPUESTA FARMACOLOGICA
CLASE IC
I IIa IIb III
STEMI + DOLOR PRECORDIAL
ISQUEMIA RECURRENTE
INESTABILIDAD HEMODINAMICA
FUNCION VENTRICULAR DEPRIMIDA
AREA MIOCARDICA DE RIESGO GRANDE
IACB + CAT + CIRUGIA
ACC/AHA 2007 STEMI Guidelines Focused Update
14
SHOCK CARDIOGENICO
BALON INTARORTICO DE CONTRAPULSACION (IABP)
CLASE II a
I IIa IIb III
STEMI + TAQUICARDIA VENTRICULAR POLIMORFA
I IIa IIb III
STEMI + ICC
ACP
ACC/AHA 2007 STEMI Guidelines Focused Update
SHOCK CARDIOGENICO
IMA
ACP PRIMARIA O DE RESCATE EN STEMI:
I IIa IIb III
DEBE REALIZARSE –IB•en pacientes severa (ICC) (Killip clase 3)
• con Sx < 12 horas
I IIa IIb III
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-
SHOCK CARDIOGENICO
IMA
APC POSTERIOR A FIBRINOLISIS
APC debe ser realizada en pacientes con:
I IIa IIb III
I IIa IIb III
Evidencia objetiva de IMA recurrente
Isquemia miocardica moderada o severa, ya sea
espontanea o provocada, durante la recuperacion
STEMI
I IIa IIb III
Shock cardiogenico o inestabilidad hemodinamica.
FIBRINOLÍSIS
REPERFUSIÓN
ACC/AHA 2007 STEMI Guidelines Focused Update
SHOCK CARDIOGENICO
CLASE I
I IIa IIb III
FIBRINOLISIS
–CUANDO INTERVENCION ESTA
CONTRAINDICADA
I IIa IIb III
MONITOREO HEMODINAMICO INTRAARTERIAL
ECOCARDIOGRAFIA
–(EVIDENCIAR COMPLICACIONES MECANICAS)
SHOCK CARDIOGENICO
REVASCULARIZACION
REVASCULARIZACION DE
ESTABILIZACION
(P=0.11)
EMERGENCIA
MEDICA INICAL
MORTALIDAD 30
DIAS
46.7%
6 A 12 MESES
53.3%
(P<0.03)
50.0%
66.4%
THE SHOCK TRIAL
ACC/AHA 2007 STEMI Guidelines Focused Update
21
SHOCK CARDIOGENICO
CLASE II
I IIa IIb III
REVASCULARIZACION TEMPRANA
• < 75 AÑOS
• ST
• BCRI
• SHOCK < 36 HS DEL IMA
• INTERVENCION < 18 HORAS
• > 75 AÑOS INDICACION IIaB
I IIa IIb III
CATETER PULMONAR
Right Ventricular Infarction
V4R
Modified from Wellens. N Engl J Med
1999;340:381.
Clinical 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
SHOCK CARDIOGENICO
SOSPECHA DE IMA VD
STEMI + INESTABILIDAD HEMODINAMICA
INFERIOR
CLASE I
I IIa IIb III
EKG + V4R
ECOCARDIOGRAMA
I IIa IIb III
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
Ventricular
Septal Rupture
Incidence
Timing
Phy Exam
Thrill
Echo
PA cath
1-2%
3-5 d p MI
murmur 90%
Common
Shunt
O2 step up
Free Wall
Rupture
Mitral Regurgitation
(Pap. M. dysfunction)
1-6%
3-6 d p MI
JVD, EMD
No
Peric. Effusion
Diast Press Equal.
Images:Courtesy of W D Edwards (Mayo Foundation)
Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426.
1-2%
3-5 d p MI
murmur 50%
Rare
Regurg. Jet
c-v wave in PCW
SHOCK CARDIOGENICO
REGURGITACION MITRAL
I IIa IIb III
RUPTURA DE MUSCULO PAPILAR
CIRUGIA URGENTE
CONCOMITANTE CABG
Mitral Regurgitation
(Pap. M. dysfunction)
SHOCK CARDIOGENICO
RUPTURA SEPTAL O DE PARED LIBRE
I IIa IIb III
CIRUGIA URGENTE
CABG
Ventricular
Septal Rupture
SHOCK CARDIOGENICO
ANEURISMA VENTRICULAR
I IIa IIb III
STEMI + AV + ARRITMIA INTRATABLE Y/O SHOCK
ANEURISMECTOMIA + CABC
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.
ACC/AHA 2007 STEMI Guidelines Focused Update
31
PAZ MUNDIAL
ACC/AHA 2007 STEMI Guidelines Focused Update
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