This handout is for cardiogenic shock — acromegaly-induced cardiomyopathy. Your care team identified this based on: cardiogenic shock (sbp <90 + lactate ≥2 + aki / cool extremities) in patient with known acromegaly or classic phenotype (frontal bossing, prognathism, enlarged hands/feet, soft-tissue swelling).
Other reasons your team may use this plan: echo with biventricular concentric hypertrophy + lv systolic dysfunction (lvef <35%) + shock physiology — acromegaly cardiomyopathy end-stage; markedly elevated igf-1 (age-adjusted >uln) in shock patient with cardiomyopathy of unclear etiology — acromegaly screen; known acromegaly patient (on or off somatostatin analog) with progressive hf now decompensated to shock — established acromegaly cardiomyopathy.
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 | 0.05–0.5 µg/kg/min titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382 — NE first-line in CS; AVOID dopamine in acromegaly (paradoxical somatotroph stimulation worsens GH secretion) |
| milrinone | 0.125–0.5 µg/kg/min IV continuous (no bolus) | IV | continuous | Inodilator; reduces SVR + improves cardiac output; preferred in biventricular failure pattern of acromegaly cardiomyopathy; ACC/AHA 2022 HF (PMID 35363499) |
| dobutamine | 2.5–10 µg/kg/min | IV | continuous | DOREMI PMID 33704937 — non-inferior to milrinone; cautious in hypertrophic LV (preload-sensitive) |
| furosemide | 20-40 mg IV bolus titrate cautiously (preload-sensitive LV) | IV | as scheduled | DOSE PMID 21366472; CAUTIOUS in hypertrophic LV (small volume changes cause large pressure shifts) |
| octreotide | 50 µg IV bolus then 100-500 µg SC q8h; transition to octreotide LAR 20 mg IM monthly once stable | IV/SC/IM | q8h SC or monthly LAR | Endocrine Society 2014 PMID 25356808; reduces GH/IGF-1 within hours-days; may improve cardiac function over weeks per Colao 2004; first-line medical therapy for acromegaly |
| lanreotide | 120 mg SC q4 wk depot (Autogel formulation) | SC | q4 wk depot | Endocrine Society 2014 PMID 25356808; depot somatostatin analog alternative to octreotide LAR; equivalent efficacy |
| pegvisomant | 10 mg SC daily, titrate to 30 mg daily based on IGF-1 | SC | daily | Trainer 2000 NEJM — normalizes IGF-1 in >90% per pivotal trial; second-line for GH-resistant or intolerant patients |
| cabergoline | 0.5 mg PO twice weekly, titrate to 3.5 mg/wk | PO | twice weekly | Endocrine Society 2014 PMID 25356808; ADD-ON only — generally INEFFECTIVE in acute CS setting (long onset; only suppresses small adenomas); useful for prolactin co-secreting adenomas after stabilization |
| hydrocortisone | 100 mg IV q8h then taper | IV | q8h | STAT replacement before any pituitary intervention if cortisol <5 µg/dL or pituitary apoplexy suspected; Endocrine Society 2014 PMID 25356808 |
| carvedilol | 3.125 mg PO BID titrate (after off catecholamines ≥24 h) | PO | BID | COPERNICUS PMID 11386262 / CAPRICORN PMID 11356436; AVOID during active shock (hypertrophic LV depends on atrial kick); start ONLY in recovery phase after off catecholamines |
| sacubitril-valsartan | 24/26 mg PO BID titrate to 97/103 BID | PO | BID | PIONEER-HF PMID 30403955; recovery phase only; acromegaly cardiomyopathy with persistent HFrEF benefits from standard 4-pillar GDMT |
| spironolactone | 12.5–25 mg PO daily | PO | daily | RALES PMID 10471456; recovery phase only |
| empagliflozin | 10 mg PO daily | PO | daily | EMPULSE PMID 35347356; particularly useful given DM common in acromegaly (GH-induced insulin resistance) |
Plan: Acromegaly cardiomyopathy with CS — NE first-line + AVOID dopamine + cautious volume + somatostatin analog (octreotide / lanreotide) + pegvisomant if GH-resistant + concurrent OSA management + MCS bridge if refractory
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Endocrinology + cardiology co-management; pituitary surgery evaluation (transsphenoidal first-line) once stable; stereotactic radiosurgery if surgery fails / residual; long-term somatostatin analog or pegvisomant if surgery + radiation incomplete; serial IGF-1 every 3 mo until normalized then every 6-12 mo; serial echo at 3 mo + 6 mo + 12 mo for heart pumping strength (LVEF) recovery; ICD/WCD evaluation if heart pumping strength (LVEF) <35% on full the four foundational heart-failure medications; advanced HF + transplant if no recovery; OSA management (CPAP); annual cardiac MRI for fibrosis surveillance; visual field testing if macroadenoma
Guideline: Endocrine Society 2014 Acromegaly Clinical Practice Guideline (Katznelson PMID 25356808) + 2022 ACC/AHA/HFSA HF Guideline (Heidenreich PMID 35363499) + SCAI 2022 CS staging (Naidu PMID 35718438)