Patient handout

Cardiogenic shock — anthracycline-induced cardiomyopathy with shock physiology

PRODUCTION

1. Your condition

This handout is for cardiogenic shock — anthracycline-induced cardiomyopathy with shock physiology. Your care team identified this based on: cumulative doxorubicin >450 mg/m² (or equivalent — daunorubicin >550, epirubicin >900) + acute lv dysfunction + shock physiology → anthracycline-cmp with cs.

Other reasons your team may use this plan: concurrent / sequential anthracycline + trastuzumab + acute lv dysfunction with hypoperfusion → additive cardiotoxicity per slamon 2001 pmid 11248153; severe global lv dysfunction (ef <30) with diffuse pattern (not single coronary territory) on echo + gls markedly reduced + recent anthracycline exposure; persistent high-sensitivity troponin elevation during anthracycline therapy + new lv dysfunction (cardinale circulation 2004 pmid 15067104 — predicts later cardiotoxicity).

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	0.05–0.5 µg/kg/min titrate MAP ≥65	IV	continuous	SOAP-II PMID 20200382 — NE first-line in CS
dobutamine	2.5 µg/kg/min cautious titration	IV	continuous	DOREMI PMID 33704937 — non-inferior to milrinone; CAUTION in dilated anthracycline myopathy given arrhythmia substrate
carvedilol	3.125 mg PO BID; titrate q2 wk to 25 mg BID (50 mg BID if >85 kg)	PO	BID	Cardinale 2015 PMID 25956652 — carvedilol + enalapril partial recovery in 64% of anthracycline-CMP within 6 mo of cardiotoxicity onset; AHA/ACC/HFSA 2022 HF Guideline (PMID 35363499); preferred β-blocker in cardio-onc per ESC 2022 (PMID 36017575) given antioxidant property
sacubitril-valsartan	24/26 BID start; titrate to 97/103 BID	PO	BID	PARADIGM-HF PMID 25176015 — ARNI superior to ACEi in HFrEF; reasonable extrapolation to anthracycline-CMP per ESC 2022 cardio-oncology
lisinopril	2.5–5 mg daily; titrate to 20–40 mg daily	PO	daily	Cardinale 2015 PMID 25956652 — enalapril prevented further LV decline + drove partial recovery in 64%; PRADA trial (Heck JAMA Cardiol 2021) — candesartan/metoprolol prevented LVEF decline during anthracycline therapy
spironolactone	25 mg daily	PO	daily	RALES PMID 10471456 — spironolactone in HFrEF; AHA/ACC/HFSA 2022 HF Guideline class I
empagliflozin	10 mg daily	PO	daily	EMPEROR-Reduced PMID 32865377; HOMER trial ongoing for anthracycline-CMP specifically; ESC 2022 cardio-oncology supports SGLT2i in HFrEF post-cardiotoxicity
dapagliflozin	10 mg daily	PO	daily	DAPA-HF PMID 31535829 — dapagliflozin alternative SGLT2i in HFrEF
amiodarone	150 mg IV bolus then 1 mg/min × 6 h then 0.5 mg/min	IV	continuous	AHA 2020 ACLS Class IIb for refractory VT/VF; relevant in dilated anthracycline-CMP arrhythmia substrate
dexrazoxane	10:1 ratio with doxorubicin (10 mg dexrazoxane per 1 mg doxorubicin) IV pre-anthracycline	IV	pre-each anthracycline cycle	Swain JCO 1997 PMID 9263800 — FDA-approved cardioprotectant for metastatic breast cancer patients receiving cumulative doxorubicin ≥300 mg/m² who would benefit from continued anthracycline; ESC 2022 cardio-oncology + AHA 2022 cardio-oncology recognize indication
DISCONTINUE further anthracycline	Oncology + cardio-onc joint decision — switch to non-cardiotoxic regimen (taxane, capecitabine, immunotherapy per cancer type)	n/a	n/a	ESC 2022 cardio-oncology PMID 36017575 — discontinuation of cardiotoxic agent is the cornerstone; oncology may switch to non-cardiotoxic regimen per cancer type

Plan: Anthracycline-CMP cardiogenic shock — supportive + GDMT 4-pillar cardioprotection per Cardinale 2015 + early MCS bridge to recovery + cancer-treatment continuation balance

3. When to call your provider

Contact your care team if any of the following happen:

Sustained VT / syncope → EP urgent consult; consider catheter ablation; ICD
Persistent severe LV dysfunction → transplant evaluation if cancer disease-free per modern criteria
Cancer recurrence → oncology + cardio-onc joint decision on therapy choice (avoid further anthracycline if possible)

4. When to seek emergency care

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

Cumulative doxorubicin >450 mg/m² (or daunorubicin >550, epirubicin >900) + new heart pumping strength (LVEF) decline ≥10 absolute or to <50% — anthracycline cardiotoxicity confirmed; emergent oncology + cardio-onc decision to discontinue further anthracycline; consider dexrazoxane only if continued anthracycline benefit per FDA label (metastatic breast cancer)
Refractory severe LV dysfunction with refractory shock in anthracycline-CMP — transplant evaluation despite cancer history; historical ISHLT 2016 disease-free interval ≥5 yr for solid tumors / ≥1 yr for hematologic being relaxed; case-by-case per modern criteria with cardio-onc + transplant + oncology MDT(life-threatening)
Sustained VT/VF or recurrent shocks within 24 h in dilated anthracycline-CMP — high arrhythmia risk in dilated chamber substrate; amiodarone + EP + escalate to MCS; ICD evaluation if cancer-prognosis permits(life-threatening)

5. Follow-up

Repeat echo + GLS at 4–8 wks for recovery trajectory; CMR at 4–8 wks; long-term the four foundational heart-failure medications 4-pillar maintenance; continued cardio-oncology surveillance (annual echo + GLS); ICD eligibility per AHA 2017 VA/SCD with cancer-prognosis weighting; oncology coordination for ongoing cancer care; dexrazoxane consideration if continued anthracycline therapy required (FDA-approved for metastatic breast cancer ≥300 mg/m² doxorubicin per Swain JCO 1997 PMID 9263800)

6. Sources

Guideline: Lyon et al ESC 2022 cardio-oncology guideline (PMID 36017575); AHA 2022 cardio-oncology scientific statement; Cardinale et al JACC 2015 enalapril cardioprotection (PMID 25956652); Plana et al JASE/EACVI 2014 echo cardio-oncology consensus; Cardinale Circulation 2004 troponin early marker (PMID 15067104)