Clinical Commander

All dossiers
cardio.cardiogenic-shock.after-non-cardiac-surgery.v1

Cardiogenic shock — after non-cardiac surgery (perioperative)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to cardiogenic shock developing within 7 days after non-cardiac surgery. Differential: perioperative MI (mostly type-2 demand mismatch from anemia + tachycardia + hypotension + sympathetic surge), perioperative PE (POD 3–7 peak), occult CS, MINS (8–19% incidence per VISION PMID 24686072 with 30-d mortality 9.8%), mechanical complication. Centerpiece is DRIVER-DIRECTED therapy: transfuse to Hgb 7–8 if anemia + ischemia (REALITY PMID 33667520), control pain to reduce sympathetic surge, optimize volume per FENICE, CONTINUE pre-op ASA + statin + BB (do NOT initiate de novo BB per POISE PMID 18479744 — increased stroke + death), CONSIDER dabigatran 110 BID for MINS per MANAGE (PMID 30340966 — 28% reduction in major vascular events), individualized DAPT/lytic decisions balanced with post-op bleed risk per POISE-2 (PMID 24679062) + POISE-3 (PMID 36286687) + 2024 ACC/AHA Perioperative (PMID 39236235). Manifest pointer reuses cardio.cardiogenic-shock.core.v1 manifest. Design-brief pointer reuses parent (perioperative differences documented inline). AVOID rules: aggressive BP lowering (POISE — hypotension is dominant MINS driver); fluid bolus without preload-responsiveness assessment (FENICE); de novo BB initiation peri-op (POISE harm); dabigatran if CrCl <30 (MANAGE + label); thrombolysis is RELATIVE CI in recent surgery (case-by-case for massive PE). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as Phase E wave 8 variant.

Entry points (4)

  • lab_abnormality
    Post-op troponin elevated within 30d of non-cardiac surgery → screen for MINS (8–19% incidence per VISION PMID 24686072)
    perioperative_troponin_elevated
  • vital_abnormality
    POD 0–7: SBP <90 + lactate ≥2 + hypoperfusion → perioperative CS workup
    perioperative_hypotension_with_lactate
  • symptom
    Post-op dyspnea + chest pain + tachycardia → screen for perioperative MI vs PE vs occult CS
    post_op_dyspnea_chest_pain
  • imaging
    New LV dysfunction on post-op echo (drop ≥10 EF points from pre-op baseline)
    echo_post_op_new_lv_dysfunction

Required inputs (10)

  • sbprequired
    vital • used at RED_FLAGS
    Sustained SBP <90 / MAP <65 drives CS-trigger threshold; POISE-3 (PMID 36286687) hypotension-avoidance strategy emphasizes intra/post-op MAP ≥80
  • hrrequired
    vital • used at CONTEXT
    Tachycardia is type-2 ischemia trigger; bradycardia from BB on board may unmask CS
  • troponinrequired
    lab • used at INITIAL_WORKUP
    STAT troponin within 24h post-op is core MINS screen — VISION 8–19% incidence; threshold ≥65 ng/L hs-cTnT or ≥20 ng/L hs-cTnI absolute change drives prognosis (Devereaux JAMA 2014 PMID 24686072)
  • lactaterequired
    lab • used at RED_FLAGS
    SCAI 2022 staging marker; rising lactate post-op flags CS overlap
  • hgbrequired
    lab • used at INITIAL_WORKUP
    Anemia is leading driver of type-2 demand mismatch in MINS; transfusion threshold 7–8 g/dL per REALITY (PMID 33667520) + TRICC framework; restrictive strategy proven non-inferior in stable patients but liberal preferred for active ischemia
  • creatininerequired
    lab • used at CONTEXT
    Post-op AKI common; eGFR for drug dosing + dabigatran/DOAC consideration per MANAGE (PMID 30340966)
  • echo_bedsiderequired
    imaging • used at INITIAL_WORKUP
    STAT bedside echo for new LV/RV dysfunction, valvular issue, tamponade exclusion, fluid responsiveness assessment
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    STAT ECG — type-1 STEMI pattern triggers cath lab; type-2 demand mismatch usually shows non-specific changes (T-wave inversions, ST depressions)
  • surgery_type_and_podrequired
    history • used at CONTEXT
    Surgery type drives risk (vascular > intra-abdominal > orthopedic); post-op day (POD) drives differential — POD 0–2 (myocardial event, hemorrhage), POD 3–7 (PE peak), POD >7 (sepsis predominant)
  • preop_meds_heldrequired
    history • used at CONTEXT
    BB withdrawal post-op is rebound risk (POISE trial framework); ASA continuation decision per POISE-2 PMID 24679062; statin continuation strongly recommended

12-phase flow (11)

  1. 1FRAME
    Perioperative CS = 4 candidate etiologies (MINS/perioperative MI, PE, occult CS, mechanical) developing within 7d post non-cardiac surgery; differentiate via troponin pattern, ECG, echo, CTPA timing; address underlying driver before escalating MCS
    inputs: sbp, lactate
    advance: Differential framed + dominant driver hypothesized
  2. 2ENTRY
    POD assessment + surgery type + pre-op medications held + STAT vitals + troponin + lactate + hgb
    inputs: sbp, hr, surgery_type_and_pod
    advance: Initial post-op CS recognized
  3. 3CONTEXT
    Pre-op cardiac risk (RCRI), surgery type, intraoperative events (hypotension burden, blood loss, transfusion), pre-op meds (BB, ASA, statin, ACEi held vs continued), AC status, code status
    inputs: preop_meds_held, creatinine
    advance: Context complete
  4. 4RED_FLAGS
    Massive bleed + hemorrhagic shock (re-exploration); STEMI pattern (cath lab); massive PE (CTPA + thrombolysis vs catheter-directed); cardiac tamponade after thoracic/abdominal surgery (drainage)
    inputs: sbp, lactate
    actions: cardiogenic_shock, cardiac_tamponade
    advance: Tier-1 red flag triaged
  5. 5INITIAL_WORKUP
    STAT troponin (MINS screen) + ECG + echo + lactate + hgb + BMP + CBC + coags; CTPA if PE suspected (post-op risk elevated, Caprini score helps); CXR; bedside POCUS for IVC + lung + abdomen
    inputs: troponin, ecg, echo_bedside, lactate, hgb
    actions: cardiogenic_shock, panel.cardiac, panel.coag, panel.renal
    advance: Etiology classified (MINS vs PE vs occult CS vs mechanical)
  6. 6BRANCHING_WORKUP
    Type-1 STEMI → cath lab activation; massive PE → systemic or catheter-directed thrombolysis (weigh post-op bleed); MINS without ACS pattern → optimize medical therapy + dabigatran consideration per MANAGE; mechanical issue → surgical consult
    inputs: ecg, troponin
    actions: acs_pathway
    advance: Etiology-specific intervention selected
  7. 7RISK_STRATIFICATION
    SCAI 2022 stage + RCRI baseline + MINS criteria (troponin elevation); CardShock if mixed
    inputs: lactate
    advance: Risk stratified
  8. 8TREATMENT
    Address underlying DRIVER first: transfuse to Hgb 7–8 if anemia + ischemia (REALITY PMID 33667520); cautious volume per FENICE; analgesia to reduce sympathetic surge; aspirin + statin CONTINUATION (do NOT initiate de novo BB intra-op per POISE PMID 18479744); NE if MAP <65 (SOAP-II PMID 20200382); dobutamine if low CI; consider dabigatran 110 mg BID for MINS per MANAGE (PMID 30340966); revascularization decision per 2024 ACC/AHA Perioperative (PMID 39236235)
    inputs: sbp, lactate, hgb
    actions: protocol.cardiogenic_shock
    advance: Underlying driver addressed + pressor/inotrope strategy active
  9. 9DISPOSITION
    Post-op CICU vs SICU; cardiology consult mandatory for MINS; advanced HF center transfer if persistent shock + non-recoverable LV
    advance: Disposition assigned
  10. 10MONITORING
    A-line + central line; serial troponin q6h × 24h post-event; lactate q1–2h until clearing; daily echo; continuous ECG; daily BMP; surgical-site monitoring (re-bleed risk)
    inputs: lactate, troponin
    actions: panel.cardiac, panel.renal
    advance: Monitoring cadence established
  11. 11FOLLOWUP
    MINS triggers post-op cardiology follow-up at 30d (high 30-d mortality 9.8% per VISION); secondary prevention initiation (ASA, statin, BB, ACEi as appropriate); cardiac rehab; re-evaluate AC strategy per MANAGE; pre-op risk stratification for future surgeries
    advance: Post-MINS plan + secondary prevention initiated