General hemodynamic principles
› Fixed obstruction physiology strategy
› Preload optimization
› Small fluid bolus option for hypotension
› Avoid over-resuscitation in pulmonary edema
› Sinus rhythm and rate control
› Atrial kick preservation
› Avoid tachycardia
› Avoidance of abrupt afterload reduction
› Nitrate caution
› Aggressive vasodilator caution
› Pulmonary edema management
› Noninvasive ventilation
› CPAP or BiPAP for work of breathing reduction
› Hemodynamic monitoring for preload reduction intolerance
› Furosemide IV 20 mg
› If loop diuretic naive, 20 mg to 40 mg option
› If chronic loop diuretic use, at least home dose IV equivalent
› Re-dose based on urine output and blood pressure
› Nitroglycerin avoidance in severe aortic stenosis with marginal blood pressure
› If used, small titrated doses with invasive monitoring
› Stop if hypotension develops
› Vasopressor and inotrope strategy
› Phenylephrine IV infusion 0.2 mcg/kg/min to 2 mcg/kg/min
› Titrate every 2 minutes to perfusion
› Bradycardia risk monitoring
› Coronary perfusion support via diastolic pressure
› Norepinephrine IV infusion 0.02 mcg/kg/min to 1 mcg/kg/min
› Titrate every 2 minutes to mean arterial pressure goal
› Tachyarrhythmia risk monitoring
› Preferred when mixed distributive and cardiogenic features
› Dobutamine IV infusion 2.5 mcg/kg/min to 20 mcg/kg/min
› If low-output state with adequate blood pressure support
› Titrate every 10 minutes to perfusion and urine output
› Stop if significant tachycardia or ischemia
› Atrial fibrillation management
› If unstable, synchronized cardioversion
› 120 J to 200 J biphasic initial strategy
› Escalation with repeated attempts
› If stable, amiodarone IV 150 mg over 10 minutes
› Then 1 mg/min for 6 hours
› Then 0.5 mg/min for 18 hours
› QT prolongation monitoring
› If rate control needed and blood pressure tolerates, metoprolol IV 2.5 mg
› Repeat every 5 minutes to total 15 mg
› Avoid in cardiogenic shock without pressor support
› Bradyarrhythmia management
› If unstable bradycardia, transcutaneous pacing
› Analgesia and sedation planning
› Transvenous pacing preparation if refractory
Definitive therapy and bridging
› Valve intervention pathway
› Aortic valve replacement for symptomatic severe aortic stenosis
› Class I recommendation in major society guidelines
› Valve team evaluation for SAVR vs TAVR selection
› Balloon aortic valvuloplasty as bridge option
› Temporary gradient reduction
› Use in cardiogenic shock or urgent noncardiac surgery setting
› Concomitant coronary evaluation planning
› Coronary angiography consideration in angina or risk factors
› Revascularization coordination with valve strategy
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