Cardiogenic shock: tips and updates

00:25 Classification of the 2 big types and 4 subtypes of cardiogenic shock, and which one need immediate cath- Pitfalls of NSTEMI-shock and HF-shock
07:13 Support devices. Pitfalls of IABP SHOCK II and ECLS shock trials vs DanGer
09:38 DanGer shock trial key features and interpretation
14:58 U shape curve of benefit
19:35 IMPORTANT summary slide: when to cath and when to support based on the 4 subtypes of shock
21:44 See my comment in comments section. SCAI stages of shock, update
26:19 General rapid escalation algorithm and U curve
29:57 Impella before or after PCI?
32:37 Fellows’ questions:
32:37 Echo before Impella in STEMI shock?
33:39 Women do not derive a benefit in DanGer shock?
35:25 Diuretics only for normotensive stage C shock?
37:13 Does Impella improve coronary perfusion pression in the presence of a stenosis
38:00 How to follow patient and when to wean?
43:43 Board question: simple summary of PV loops and PV area with various MCS devices

[@eliashanna8248]

Further clarification of SCAI shock stages
INITIAL classification:
-Initial stage C: lactate 2-5
-Initial stage D: lactate 5-10 or ALT >500
-Initial stage E: Lactate >10 or SBP

[@ahmeddaoud9901]

Advanced Thanks for you Dr Hanna.

[@draksingh8034]

Thank you Dr Hanna. You have very well explained which patients of cardiogenic shock should go immediately for cath. You have clearly defined the fine lines between various stages of shock and its "U" shaped graph to exactly pick up patients to benefits from MCS.

[@ap294673]

You are god sent!

[@Nikesnipe]

Thanks a lot

[@ap294673]

I don’t like performing LV gram in acute MI shock patients. Adding more volume worsens the shock. An ECHO is easier to perform and can answer all the Qs.

[@taytay-ct4yv]

Thank you so much for sharing this video, I really enjoyed it! I'm quite interested in the topic. Would it be possible for you to share the PowerPoint file with me? I'd love to delve deeper into the content.

[@youssefnassef1564]

In light of new ESC ACS guidelines
Urgent PCI is indicated in NST-ACS with hemodynamic collapse, how can we understand this in light of the indirect message understood from culprit-shock "avoid intervention unless for clear culprit"

[@namphan6911]

Thank you for a fantastic lecture, once again. Unfortunately, where I'm working, we don't have the Impella yet. As such, we only have IABP and ECMO. I know we don't have sufficient data to come to conclusion, as well as both the IABP-SHOCK and ECLS trials being much different than the Danger-Shock, but in your opinion, do you think the timing of ECMO/IABP in AMI-CS can be applied the same way as the Impella?

[@eliashanna8248]

Thank you. Hopefully, your institution will get Impella after Danger Shock trial. Exactly as you mention, both IABP and ECMO failed in MI shock in those 2 trials. Since you don't have Impella, I may suggest the following, for STEMI shock within 24 hours of STEMI and of the shock (preferably within few hours):
-Initial stage C (lactate 2-5) that is unresponsive to 1 medium inopressor: upscale inopressor vs consider IABP
-Initial stage D or E (lactate >5) or subsequent stage D or E with >2-3 inopressors: ECMO if they are actively destabilizing, or IABP if they stabilize on 2-3 inopressors.
For all of those groups, the standard now should be to start with Impella CP within few hours of the shock, when available.
I would exclude post-cardiac arrest shock.
Also, as I explained at the end of the lecture, under PV loops, ECMO raises LV pre- and afterload, and you may need LV venting. One major pitfall of ECLS shock trial is that only 5.8% of patients received LV venting. So, I would keep a low threshold to use LV venting with ECMO; at our institution, Impella CP or 5.5 is most commonly used for venting, but consider using IABP instead since that is what you have.

[@SathishKumar-jd3zi]

Thank you dr hanna for the wonderful explanation for shock management.one question sir,in nstemi shock without st depression.if you stabilize the patient,then when you take him for cath? Is there any time limit before you take him for cath?

[@eliashanna8248]

There is no specific time limit. It could be 1 to several days, depending on each case. The key is to properly diurese and nearly normalize filling pressures to allow him to tolerate PCI and not destabilize during PCI (for the reasons explained under 05:20). You may need pressors and may need a support device in that interim period based on the shock escalation strategy (although no one specific support device is proven useful in this scenario).

[@Mohamed-cz7kc]

❤