Patient handout

ADHF complicated by cardiogenic shock (composite)

PRODUCTION

1. Your condition

This handout is for adhf complicated by cardiogenic shock (composite). Your care team identified this based on: adhf + sbp <90 sustained or vasopressor-dependent — scai b+ shock complication.

Other reasons your team may use this plan: adhf + cool extremities + lactate ≥2 + aki + ams — nohria-stevenson cold-wet profile; adhf + serial lactate rising despite iv diuretic — perfusion failure pattern; adhf with new severely reduced lvef on bedside echo + low-output state.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
norepinephrine	0.05 µg/kg/min	IV	continuous; titrate to MAP ≥65	SOAP-II PMID 20200382 — first-line vasopressor in cardiogenic shock; arrhythmia rate 12.4% vs 24.1% with dopamine
vasopressin	0.03 U/min	IV	continuous; not titrated	V1-mediated vasoconstriction sparing pulm vasculature; second pressor in refractory shock (AHA 2020 + ACC/AHA 2022 HF)
dobutamine	2.5 µg/kg/min	IV	continuous; titrate to perfusion + UOP	AHA 2020 Class IIb; restores perfusion enabling diuresis; arrhythmia risk
milrinone	0.125-0.5 µg/kg/min (no bolus)	IV	continuous; renal adjust	OPTIME-CHF PMID 11887962; longer half-life; renal adjustment required; alternative inodilator if dobutamine intolerant
furosemide	IV bolus + continuous infusion 5-20 mg/h AFTER MAP restored to ≥65	IV	continuous infusion preferred	DOSE PMID 21366472 — decongest only after perfusion adequate; tolerate moderate Cr rise per CARRESS-HF PMID 23131078
acetazolamide	500 mg IV/PO daily × 3	IV/PO	once daily	ADVOR PMID 36027564 — improves decongestion at 3 d when added to loop
sacubitril-valsartan	24/26 mg BID — ONLY after off IV inotropes + SBP ≥100 + 36h post-ACEi	PO	BID	PIONEER-HF PMID 30403955 — start in-hospital after stabilization; EMPULSE PMID 35347356 for SGLT2i timing
carvedilol	3.125 mg BID — ONLY after off inotrope ≥24h + euvolemic + SBP >100	PO	BID; titrate q2 wks	COPERNICUS PMID 11386262 — start at low dose once decongested + off inotrope; HOLD during shock
spironolactone	12.5-25 mg daily — only after K <5 + eGFR ≥30	PO	daily	RALES PMID 10471456 / EMPHASIS-HF PMID 21073363
empagliflozin	10 mg daily — start in-hospital once stabilized	PO	daily	EMPULSE PMID 35347356 — start in-hospital; safer than ARNI/BB during recovery; reno-cardiac protective

Plan: ADHF + cardiogenic shock concurrent regimen — perfusion FIRST, then decongestion

3. When to call your provider

Contact your care team if any of the following happen:

ICD therapy delivered → urgent EP
EF declining → LVAD/transplant

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

ADHF-CS escalating from SCAI B (beginning) to SCAI D (deteriorating) or E (extremis) — failing initial pressor + inotrope(life-threatening)
New harsh holosystolic murmur OR new severe MR/AR/VSR on echo in ADHF-CS context(life-threatening)
Recurrent VT/VF storm in ADHF-CS context — often peri-infarct or scar-mediated(life-threatening)
Cr rise >50% from baseline + persistent congestion in ADHF-CS — type-1 cardiorenal syndrome
No lactate clearance + escalating MCS support + multi-organ failure + non-LVAD/transplant candidate
EF <25% + NYHA III-IV + recurrent decompensations despite max the four foundational heart-failure medications — advanced HF NYHA D

5. Follow-up

Advanced-HF clinic follow-up; the four foundational heart-failure medications 4-pillar resumption per STRONG-HF cadence; ICD/CRT eligibility per heart pumping strength (LVEF) at 40-90 d; LVAD/transplant evaluation if persistent advanced HF; cardiac rehab; mental health (high PTSD risk in CS survivors)

6. Sources

Guideline: 2022 ACC/AHA HF + 2023 Focused Update + SCAI 2022 CS staging + DanGer Shock 2024 + STRONG-HF 2022