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