Clinical Conference 10/23/07

76 y.o. with h/o HTN, presented to Palos ER with SSCP SH: remote tob FH: no early CAD All: NKDA Meds: lisinopril 5mg

OSH ER course Initial Vitals: 89/60, P96, RR 28 Defibrillation 150J x 3 Placed on 100% NRB IV lidocaine bolus and gtt Plavix 600mg, Lipitor 80mg, ASA 325mg Taken to Cath Lab

Cath Lab course Initial Central aortic pressure 92/67, then decreased to 75/52 Started on Dopamine 5mcg  20mcg Reopro IV During LAD balloon inflations, no peripheral pulse; CPR begun, Anesthesia called to intubate, IABP placed, Epinephrine/Atropine given

Cath Lab course, continued Phenylephrine gtt then Levophed gtt started  maxed Multiple balloon dilations, followed by stent placements: BMS x 3 Post-intervention, vitals BP 71/51 P112 on max Dopamine, Levophed, Phenylephrine and IABP 1:1

SHOCK Trial 302 patients with confirmed cardiogenic shock developing within 36 hours of an acute MI Randomly assigned within 12 hours of the diagnosis of shock to emergency revascularization (CABG in 40 percent and PCI in 60 percent) within six hours or to initial medical stabilization. Almost half of the patients assigned to emergency revascularization had had prior thrombolysis, and therefore underwent rescue PCI or CABG; 63 percent of patients in the medical arm also received thrombolytic therapy. Intra-aortic balloon counterpulsation was utilized in 86 percent of patients in both groups. RESULTS At 30 days, total mortality (primary end point) between the two treatment groups (47 versus 56 percent with initial medical therapy with thrombolysis, p = 0.11) At 1 year, early revascularization was associated with a lower mortality rate: 53 versus 66 percent At 6 years, mortality in revascularization group was 67 versus 80 percent with medical stabilization. The benefit of early revascularization was similar between patients both older and younger than 75 years.

SHOCK TRIAL: PCI versus CABG 128 patients with predominant left ventricular failure who underwent emergency revascularization in the SHOCK trial -37% patients underwent CABG versus, 63% PCI -CABG patients were more likely to have DM and 3V or LM disease -87% of CABG patients had complete revascularization versus 23% of PCI patients RESULTS: -Overall survival was similar at 30 days (57 with CABG versus 56 percent with PCI) and one year (47 versus 52 percent).

Compared LVAD after CABG versus LVAD alone Retrospective review of 74 patients who underwent LVAD after CABG or LVAD alone for AMI and cardiogenic shock. -28 w/ LVAD only -46 with LVAD after CABG RESULTS: -CABG + LVAD group had: -lower bridge to transplantation (45.50% vs 70.40%, P.041) -higher early mortality (39.10% vs 14.30%, P.020) -lower 6-month survival (54% vs 89%, p=0.006) -lower 12-month survivals (52% vs 82%, p=0.006)

Retrospective review of 138 consecutive cases of Cardiogenic shock and AMI Three groups of patients, all received intensive medical management and IABP: -conservative group (43 pts): A. intensive medical management and IABP alone -aggressive groups (95 pts): B. Revascularization (PCI or CABG) (77pts) C. Circulatory support/transplant (18 pts)

Improved 5 year survival in aggressive group. Greatest benefit (reduced in-hospital mortality) seen in patients who received circulatory support i.e. LVAD, LVAD as bridge to transplant