This handout is for cardiogenic shock — acute severe aortic regurgitation. Your care team identified this based on: sudden chest / back pain + new diastolic murmur + flash pulmonary edema + cardiogenic shock → acute severe ar with concurrent dissection until proven otherwise.
Other reasons your team may use this plan: stat tee: vena contracta ≥0.6 cm, holodiastolic flow reversal in descending aorta, premature mitral valve closure on m-mode, pht <250 ms + biventricular dysfunction + shock physiology; cta chest: stanford type a aortic dissection extending into root with cusp prolapse + acute severe ar + cardiogenic shock — concurrent surgical emergency; active infective endocarditis (s. aureus, streptococcus) + acute hemodynamic deterioration + new diastolic murmur → aortic leaflet perforation / paravalvular abscess.
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 |
|---|---|---|---|---|
| sodium nitroprusside | 0.25–0.5 µg/kg/min start; titrate to MAP 65–75 (max 10 µg/kg/min for ≤10 min) | IV | continuous | CORNERSTONE pharmacologic bridge in acute severe AR — reduces SVR → reduces regurgitant fraction → improves forward flow + reduces pulmonary edema; cyanide accumulation risk if eGFR <30 (use sodium thiosulfate co-infusion for prolonged use) |
| dobutamine | 2.5–5 µg/kg/min titrate | IV | continuous | Preferred over pressors that increase SVR (which worsens AR); supports forward flow + maintains MAP via β1 inotropy without major SVR rise; DOREMI PMID 33704937 |
| norepinephrine | 0.05 µg/kg/min start; minimize doses | IV | continuous | CAUTION — increases SVR which worsens AR severity; use lowest dose to maintain MAP ≥65; SOAP-II PMID 20200382 generally first-line in CS but in acute AR is second-line behind dobutamine + nitroprusside |
| furosemide | 40–80 mg IV bolus then infusion 5–10 mg/h | IV | bolus + continuous | Decongest after perfusion stable (ESC 2021 HF Guidelines); continuous infusion preferred for refractory pulm edema |
| vancomycin | 25–30 mg/kg IV load then 15–20 mg/kg q12h adjusted to trough 15–20 | IV | q12h | AHA 2015 endocarditis guideline empiric coverage for native valve endocarditis — gram-positive cocci dominant pathogen spectrum (Baddour PMID 26373316) |
| ceftriaxone | 2 g IV q24h | IV | q24h | AHA 2015 endocarditis guideline empiric coverage — covers Streptococcus + HACEK organisms |
| warfarin | Post-op: 5 mg daily; mechanical aortic INR target 2.0–3.0; bioprosthetic INR 2–3 × 3 mo then ASA | PO | daily | ACC/AHA 2020 valvular Class I — mechanical aortic valve INR 2.0–3.0 (vs mitral 2.5–3.5); bioprosthetic INR 2–3 × 3 mo then ASA chronic |
| esmolol (CAUTIOUS — only if dissection BP control absolutely required) | 500 µg/kg load, then 50 µg/kg/min titrate; AVOID generally | IV | continuous | CAUTION — β-blocker suppresses compensatory tachycardia in acute AR → worsens forward flow; reserve for dissection BP control when surgery is imminent and BP cannot be controlled by nitroprusside alone |
Plan: Acute severe AR + CS — emergent surgery + nitroprusside afterload reduction (cornerstone) + dobutamine inotrope + intubation often needed; AVOID IABP (worsens AR) + AVOID β-blocker pre-surgery (suppresses compensatory tachycardia)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Repeat TTE at 1 wk + 1 mo + 3 mo post-surgery for valve function + LV recovery; cardiac rehab; the four foundational heart-failure medications if persistent HFrEF; endocarditis prophylaxis per AHA 2007 if prosthetic valve; lifelong follow-up at valve clinic; long-term anticoagulation per valve type (mechanical = warfarin INR 2-3 aortic; bioprosthetic = ASA + 3 mo warfarin + ASA chronic); aortic surveillance imaging if dissection / connective tissue disease
Guideline: Otto et al ACC/AHA 2020 valvular heart disease guideline (PMID 33342587); Vahanian ESC 2021 valvular heart disease (PMID 34453165); Erbel et al ESC 2014 aortic dissection guidelines (PMID 25173340); Baddour AHA 2015 endocarditis guideline (PMID 26373316); SCAI 2022 CS staging (Naidu PMID 35718438)