This handout is for cardiogenic shock — acute severe mr from infective endocarditis. Your care team identified this based on: fever + new harsh holosystolic murmur at apex + flash pulmonary edema + hemodynamic deterioration → ie-driven acute severe mr with cs until proven otherwise.
Other reasons your team may use this plan: stat tee: mitral valve vegetation ≥10 mm + leaflet perforation / chordal destruction + acute severe mr (vena contracta ≥0.7 cm, eroa ≥0.4 cm²) + biventricular dysfunction + shock physiology; positive blood cultures (s. aureus, streptococcus viridans, enterococcus) + sudden cardiac decompensation → acute mr from leaflet perforation / chordal destruction; iv drug use history + new fever + acute heart failure + new murmur → left-sided ie with acute mr (less common than right-sided ivdu ie but higher mortality).
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 |
|---|---|---|---|---|
| vancomycin | 25–30 mg/kg IV load then 15–20 mg/kg q12h adjusted to trough 15–20 | IV | q12h | AHA 2015 endocarditis guideline (Baddour PMID 26373316) + ESC 2023 update (Delgado PMID 37622660) — empiric coverage for native valve IE includes MRSA coverage given high prevalence; trough-targeted dosing per IDSA 2020 vancomycin guideline |
| ceftriaxone | 2 g IV q24h | IV | q24h | AHA 2015 endocarditis guideline — empiric coverage for Streptococcus viridans + HACEK organisms |
| cefepime | 2 g IV q8h | IV | q8h | AHA 2015 endocarditis guideline — alternative empiric with broader gram-negative coverage when HCAP risk or IVDU with severe sepsis |
| gentamicin | 1 mg/kg IV q8h adjusted to peak/trough | IV | q8h | AHA 2015 endocarditis guideline — adjunct for prosthetic valve IE (× 2 weeks per protocol) and enterococcal IE (synergy with cell-wall agent); monitor renal function + ototoxicity |
| rifampin | 300 mg PO/IV q8h | PO/IV | q8h | AHA 2015 endocarditis guideline — biofilm penetration in prosthetic valve staphylococcal IE; × full 6-week course |
| daptomycin | 8–12 mg/kg IV q24h | IV | q24h | AHA 2015 endocarditis guideline + IDSA — alternative to vancomycin for MRSA / VRE IE; high doses (8-12 mg/kg) needed for IE per Fowler NEJM 2006 |
| norepinephrine | 0.05–0.5 µg/kg/min titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382 — NE first-line in CS / septic shock; CAUTION — pair with afterload reduction in acute MR to prevent worsening regurgitant fraction |
| dobutamine | 2.5 µg/kg/min CAUTIOUS titration | IV | continuous | DOREMI PMID 33704937 — non-inferior to milrinone; CAUTION in acute MR (may worsen MR severity by increasing LV contractility) |
| sodium nitroprusside | 0.25–0.5 µg/kg/min start; titrate to MAP 65–75 | IV | continuous | Cornerstone afterload reduction in acute severe MR — reduces regurgitant fraction + improves forward flow + reduces pulmonary edema; cyanide accumulation risk if eGFR <30 |
| nitroglycerin | 5–20 µg/min titrate up to 200 µg/min | IV | continuous | Preload reduction → reduces PCWP + V-wave + pulm edema; first-line decongestant in acute MR with preserved MAP |
| 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 |
| vasopressin | 0.03 U/min fixed | IV | continuous | V1-mediated; pulmonary-vascular sparing; SSC 2021 sepsis bundle adjunct to NE; per VANISH trial |
| warfarin | Post-op: 5 mg daily; mechanical mitral INR target 2.5–3.5; bioprosthetic INR 2–3 × 3 mo then ASA | PO | daily | ACC/AHA 2020 valvular Class I — mechanical mitral valve requires lifelong warfarin INR 2.5–3.5; bioprosthetic INR 2–3 × 3 mo then ASA chronic |
Plan: IE-driven acute severe MR + CS — empiric IV antibiotics IMMEDIATELY + emergent surgery (Class I) + IABP bridge (preferred MCS) + cautious inotrope + diuretic + afterload reduction; AVOID isolated vasoconstrictor; SOURCE CONTROL critical
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 / TEE at 1 wk + 1 mo + 3 mo + 6 mo + annually post-surgery; complete prolonged IV antibiotic course (4-6 weeks for native valve, 6 weeks + rifampin/gentamicin for prosthetic valve per AHA 2015); cardiac rehab; the four foundational heart-failure medications if persistent HFrEF; endocarditis prophylaxis per AHA 2007 (lifelong for prosthetic valves, prior IE, congenital heart disease); long-term anticoagulation per valve type; addiction medicine follow-up if IVDU; dental clearance + planned dental work; lifelong follow-up at valve / IE clinic
Guideline: Baddour AHA Infective Endocarditis 2015 (PMID 26373316); Delgado ESC Endocarditis 2023 update (PMID 37622660); Otto ACC/AHA 2020 valvular heart disease guideline (PMID 33342587); Wang JAMA 2014 — early surgery in IE survival benefit (PMID 24247733); Estévez-Loureiro JACC 2024 IREMMI registry (PMID 36440867); SCAI 2022 CS staging (Naidu PMID 35718438)