Tailored Therapy (Goal-Directed Therapy)



Tailored Therapy (Goal-Directed Therapy)

Cardiogenic Shock = Low CO state | Decompensated Heart Failure

|CO = SV x HR |CO: Cardiac Output |

|( |LVEDV: LV End Diastolic Volume |

|LVEDV x EF |EF: Ejection Fraction |

|[pic] |To improve CO, you must optimize LVEDV or EF |

| | |

| |LVEDV - Can’t measure directly, assume the following: |

| |LVEDV [pic] LVEDP ( LAP ( PCWP |

| |Intervene by diuresing or adding volume |

| | |

| |EF – Proportional to contractility |

| |Inversely Proportional to Afterload (SVR) |

| |Inotropes – Improve contractility |

| |ACE-I/Nitrates/BNP – Diminish Afterload |

Management

First Step: Categorize Your Patient

Dry vs. Wet: What is the Volume Status (PCWP, JVP, history)

Cold vs. Warm: How “clamped down” are they (SVR, peripheral limb skin temp)

Dry + Warm - Rethink Diagnosis, likely distributive problem (sepsis): Give Fluid

Dry + Cold – Overdiuresed: Easy to treat -> Fluid ± Afterload Reduction

Wet + Warm – Sodium/Water Overloaded -> Diuresis*

Wet + Cold - Decompensated Heart Failure -> Diuresis and Afterload Reduction*

*What if your patient is or becomes Hypotensive?? -> Begin Goal Directed Therapy

Tailored Therapy

-Goal: Provide inotropic support (improve EF and thus CO) so you can diurese and AL Reduce. This will in turn improve SV and eventually, you can wean inotropes and ultimately transition to oral medications.

-PA catheter: Use to measure CO, PCWP, SVR. Achieve higher CO by adjusting PCWP and SVR with your medications, without dropping your BP too low.

The Data

Lynne Stevenson et al., Am J Cardiol. 1989 Feb 15;63(7):461-4

-Non-randomized, observational Study

-50 patients transferred to UCLA for “urgent transplant”; received IV vasodilators and diuretics; measured HD improvement and survival

-HD goals: SBP>80, PCWP < 15, SVR < 1200

-inotropes were tapered off when possible and transitioned to oral therapy

-Results: 41/50 pts successfully discharged, 4 transp, 5 died. 25/41patients taken off list, 67% 1yr survival

-Remember, NOT randomized

ESCAPE Trial

Lynne Stevenson et al., Not yet Published; Data released at AHA 2004

-Randomized

-433 pt decompensated HF (failed outpt therapy)

-Excluded very sick patients: “requiring urgent PAC”, intubated, IABP

-Randomized to clinical assessment versus clinical assessment plus PAC

-PAC group goal PCWP < 15

-Outcomes (death, length of hospitalization) were similar

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