Patient handout

Cardiogenic shock — PE-related (massive PE with RV failure)

PRODUCTION

1. Your condition

This handout is for cardiogenic shock — pe-related (massive pe with rv failure). Your care team identified this based on: massive pe on ctpa + rv/lv ratio >1 + septal flattening on bedside echo.

Other reasons your team may use this plan: syncope + acute dyspnea + sbp <90 sustained → suspect massive pe; bedside echo: mcconnell sign (rv free wall hypokinesis with apical sparing) + dilated ivc + septal d-sign; elevated troponin + bnp in confirmed pe (pesi high risk → cardiogenic shock pathway).

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
alteplase	100 mg IV over 2h (or 50 mg IV push if cardiac arrest)	IV	one-time infusion	ESC 2019 Class I systemic thrombolysis for high-risk PE (Konstantinides PMID 31504429); reduced-dose 50 mg push during cardiac arrest per ELSO + AHA 2020
unfractionated heparin	80 U/kg IV bolus → 18 U/kg/h infusion, aPTT 1.5-2.5x	IV	continuous	Bridges to thrombolysis or post-lysis AC; allows rapid reversal if bleeding develops
norepinephrine	0.05-0.5 mcg/kg/min IV titrate to MAP ≥65	IV	continuous	NE preferred — maintains coronary perfusion to failing RV; SOAP-II PMID 20200382
dobutamine	2.5-5 mcg/kg/min IV (low-dose to avoid tachyarrhythmia)	IV	continuous	RV inotropic support; titrate cautiously to avoid pulmonary vasodilator-driven systemic hypotension and tachyarrhythmia
nitric oxide inhaled	20-40 ppm INH	INH	continuous	Selective pulmonary vasodilator — reduces RV afterload without systemic hypotension; bridge to clot resolution
epoprostenol inhaled	50 ng/kg/min nebulized	INH	continuous	Adjunct selective pulmonary vasodilator (often used when iNO unavailable or insufficient)
apixaban	10 mg BID × 7d → 5 mg BID × ≥6 mo (post-stabilization)	PO	BID	AMPLIFY DOAC strategy for PE; preferred over warfarin per ESC 2019

Plan: PE-related cardiogenic shock — systemic thrombolysis + RV-supporting pressors + pulmonary vasodilation; AVOID LV-only MCS

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent VTE → escalate to lifelong AC + reassess for malignancy/thrombophilia
CTEPH confirmed → pulmonary endarterectomy or balloon pulmonary angioplasty referral

4. When to seek emergency care

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

PE with hemodynamic collapse + cardiac arrest imminent → empiric reduced-dose alteplase 50 mg IV push(life-threatening)
Massive PE + absolute thrombolysis CI (recent ICH, neoplasm, surgery <2 wk) → surgical embolectomy or catheter thrombectomy(life-threatening)
Isolated LV-MCS (Impella CP) considered in PE-related CS — STOP, will worsen RV by reducing LV filling and septal interaction
No hemodynamic improvement at 1-2h post-systemic alteplase → escalate to VA-ECMO bridge(life-threatening)
New neurological deficit or AMS post-thrombolysis → STAT non-contrast CT head + reverse(life-threatening)

5. Follow-up

Long-term anticoagulation per AMPLIFY (apixaban 10 BID × 7d → 5 BID × ≥6 mo); post-PE syndrome screen at 3-6 mo (CTEPH evaluation if persistent dyspnea); thrombophilia workup if unprovoked

6. Sources

Guideline: ESC 2019 Pulmonary Embolism Guideline (Konstantinides EHJ 2019, PMID 31504429) + AHA 2011 Massive PE Scientific Statement + 2022 ACC/AHA HF (PMID 35363499) + SCAI 2022 CS staging (PMID 35718438)