Thread by @docbhardwaj

🔥Review on optimal targets in #CardiogenicShock in @JACCJournals #Advances by @benhibbertMDPhD & team 👏
Clinical, biochemical & hemodynamic targets to guide therapy & escalation of therapy.
@Sadeer_AlKindi @baileyannRN #ACCEarlyCareer #ACCFIT
👉jacc.org/doi/10.1016/j.…

Current guidelines focus on the t/t of inciting event & restore end-organ perfusion; inotropes/pressors to target MAP ≥65 mm Hg.
🏷 Asses serial markers of systemic perfusion- lactate, ScVO2, UOP, Cr, LFTs, mentation, temp, and invasive hemodynamics & target accordingly

🏷Difference in #SCAI classes A-B & C-E is presence of hypoperfusion- clinical signs like cool mottled skin, poor UOP, confusion, & biochemical abnormalities like ⬆️ lactate, renal insufficiency, and ⬆️ LFTs.
🏷 RAP, ⬆️ shock stage over time, and late deterioration ⬆️ mortality

Hemodynamic & perfusion targets
🏷 Clinical ‘Windows of perfusion’ - mentation, skin quality, UOP
🏷 PAC use
-⬇️ mortality in both MI-CS & HF-CS
-Early recognition of CS
-identify BiV dysfunction
- identify right device for right patient
- assess hemodynamic response to meds

🏷 Physical Exam- 1st indicator
-Congestion: ⬆️JVP, 🫁 rales
-Poor CI- AMS, mottled skin

🏷 Forrester classification Post MI:
warm-dry (congestion-/hypoperfusion-)
wet-warm (congestion+ hypoperfusion-)
dry-cold (congestion-/hypoperfusion+)
wet-cold (congestion+/ hypoperfusion-)

Potential clinical target- titrate therapy to target clinical euvolemia & peripheral exam suggestive of warm, well-perfused extremities.
@IRajapreyar @amitalamMD @Nikhil15 @PPirlamarla_MD

🔥 MAP- “perfusion pressure” of organs
🏷 crucial “target” of Shock resuscitation.
🏷 DBP critical variable in coronary perfusion in ischemia
🏷 No trials on target, usually~ 65 mmHg, may need to be customized.
🏷 HF-CS seemed to have better clinical outcomes with an MAP>70

🔥LA & LA clearance
⬇️tissue perfusion, microcirculatory dysfunction, ⬆️ endogenous CAs ➡️->
⬆️anaerobic metabolism-> ⬆️LA production

🏷 Acidosis->⬇️ vasopressor response, ⬇️ cardiac contractility, and altered SVR.

🏷 Serum HCO3 & base deficit may be prognostic markers in CS

🏷 No trials in LA clearance

🏷 Over 8 hrs, LA clearance -> may suggest pharmacologic stabilization & may predict who continues to improve & not require escalation, vs avoiding “missing the window” to escalate support in those patients-> i.e. predict who benefits with #MCS

🔥Mixed venous sat-
Normally, ScVO2 can be used as surrogate for SVO2, but not in CS

🏷 ScvO2 may be therapeutic target in terms of forward flow and titrating diuretics in congestion.

🏷 Low SvO2 correlating with worse outcomes among pts with severe cardiopulmonary disease

🔥 Urine Output/kidney marker

🏷 AKI in 15-55% of CS (⬆️ Cr, ⬇️ GFR/UOP)
🏷 Type 1 CRS- ⬇️ CO/renal perfusion->oliguria.
🏷 ⬆️CVP predictor for AKI
🏷 Activation of RAAS-> Na/H2O retention-> ⬆️ afterload, ⬇️ outcomes, long-term HD, ⬆️ hospitalization, short/long-term mortality

🏷 Effect of renal replacement therapy (RRT) for outcomes in patients,& what’s the optimal timing and strategy in CS is unknown.

🏷 No specific thresholds for RRT but tailored to individual patients

@AndrewJSauer @JonathanDavisHF @gmac78 @RyanTedfordMD @DhariniRamu

🔥LV/RV pressures
🏷 In STEMI, LVEDP >18 mm Hg, SBP/LVEDP <4 & ⬇️ CPO associated with poor short-term outcomes
🏷 ⬆️ RAP, RA/PCWP & ⬇️ PAPi and RVSWI values associated with ⬆️ mortality
🏷 RV failure ⬆️ with #SCAI stage
@KevinShahMD @KiranDSidhu @ShashankSinhaMD @Abraham_Jacob

🔥Other Markers
🏷 Delta CO2- P(v-a)CO2- marker for microcirculatory dysfunction- high number ~ increased severity
🏷 delta CO2 inversely proportional to CI in circulatory failure
🏷 persistently ⬆️⬆️ delta CO2 may help identify patients who remain inadequately resuscitated

🏷 PETCO2- marker of poor outcome in resuscitation in cardiac arrest

🏷 PetCO2 <10 mm Hg after 20 minutes CPR predictive of in-hospital mortality

Biomarkers
🏷CS 4 Proteins score: based on 4 proteins reflecting multiorgan dysfunction, inflammation & immune activation.
⬆️predictive values in short-term mortality alongwith clinical risk scores.

🏷CLIP- cystatin C, lactate, IL-6 NTpro–BNP-Clinical use yet to be determined

🏷 PEEP optimization in CS ~ ⬆️ myocardial contractility, ⬇️ wall tension, ⬇️ afterload, and ⬆️ arterial O2.
Preload dependent states- low PEEP with aggressive cortection of pH, PaCO2, low O2, VQ mismatch.
Afterload dependent states- high PEEP as in LV dysfunction, & severe MR

🏷 Emerging Technologies

🔥Flotrac system uses an arterial pressure waveform analysis to obtain CO, CI, SV, SV variation, and SVI; with adding a CVC, ScvO2 & SVR can also be measured.

Its reliability most studied in post op & trauma pts, ⬇️ utility in vasoplegia.

🔥 NIRS- noninvasive way to monitor tissue O2 (tissue HbO2 sat based on oxygenated and deoxygenated Hb).
🏷 Mostly used during CV surgery to identify cerebral desaturation.
🏷 Data supporting use in shock is limited.
🏷 Baseline value associated with Shock markers-SvO2 and LA

Several pressing gaps
🏷 identification of ideal MAP targets in various phenotypes of CS,
🏷 efficacy and safety of single and/or combined inotrope therapy, 🏷 ideal timing of RRT,
🏷 safety and efficacy of #MCS devices in different CS etiologies

@SrihariNaiduMD @AnkurKalraMD @Babar_Basir @DrNasrien @adityadoc1 @DrRajivsankar @SantosGallegoMD @carlosalviar @SarasVallabhMD