This handout is for cardiogenic shock — post-hematopoietic-stem-cell-transplant recipient. Your care team identified this based on: recent high-dose cyclophosphamide conditioning (≥120 mg/kg) within past 1–10 d + acute hf + ↑ troponin → cyclophosphamide hemorrhagic myocarditis (goldberg jco 1986 pmid 3528404).
Other reasons your team may use this plan: hsct recipient (allogeneic or autologous) within past 100 d + acute biventricular dysfunction + shock physiology — multi-etiology cs workup; cmv pcr positive + acute lv dysfunction in post-hsct recipient (peak 30-100 d) → cmv myocarditis differential; sepsis physiology in neutropenic post-hsct recipient with cardiac dysfunction → mixed septic + cardiogenic shock.
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 inflamed myocardium given arrhythmia risk |
| methylprednisolone | 1000 mg IV daily × 3–5 days, then 1 mg/kg/d taper | IV | daily | Goldberg JCO 1986 PMID 3528404 — high-dose corticosteroids cornerstone for cyclophosphamide hemorrhagic myocarditis; AHA 2022 cardio-oncology + ESC 2022 (Lyon PMID 36017575) |
| ganciclovir | 5 mg/kg IV q12h induction × 14–21 d (renal-adjust); maintenance 5 mg/kg IV daily | IV | q12h induction | ASTCT CMV management guideline (PMID 20530287) — IV ganciclovir is first-line for CMV end-organ disease post-HSCT including myocarditis; renal dose adjustment essential |
| foscarnet | 60 mg/kg IV q8h × 14–21 d (renal-adjust) | IV | q8h | ASTCT CMV management — ganciclovir-resistant CMV; alternative if cytopenia limits ganciclovir; nephrotoxic — monitor closely |
| immune globulin (IVIG) | 500 mg/kg IV q48h × 5 doses (CMV myocarditis adjunct) | IV | q48h | ASTCT CMV management — IVIG adjunct in severe CMV pneumonitis / myocarditis post-HSCT; may also be considered for hypogammaglobulinemia + viral myocarditis context |
| ruxolitinib | 10 mg PO BID; titrate per platelet + ANC | PO | BID | REACH-2 NEJM 2020 — ruxolitinib for steroid-refractory acute GVHD; relevant when GVHD-related cardiac involvement contributes to CS |
| 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 |
| cefepime | 2 g IV q8h (renal-adjust) | IV | q8h | IDSA neutropenic fever 2010 + ASTCT supportive-care guidelines — empirical broad-spectrum β-lactam for febrile neutropenia in HSCT recipient |
| AVOID nephrotoxic drugs | AVOID aminoglycosides, NSAIDs, contrast unless essential; minimize loop diuretics if AKI; use nephrology-stewardship lens | n/a | n/a | Calcineurin inhibitors (cyclosporine / tacrolimus) on board for GVHD prophylaxis cause AKI; avoid stacking nephrotoxins per ASTCT supportive-care guidance |
Plan: Post-HSCT cardiogenic shock — etiology-stratified support with nephrotoxin avoidance + sub-etiology-specific treatment + MDT-gated MCS bridge
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 echo + CMR at 4-8 wks for recovery trajectory; cardiac rehab; long-term the four foundational heart-failure medications 4-pillar if persistent HFrEF; long-term cardio-oncology surveillance for late TBI / busulfan effects; coordination with transplant team for chronic GVHD + immunosuppression management; ICD eligibility per AHA 2017 VA/SCD with cancer-prognosis weighting
Guideline: Lyon et al ESC 2022 cardio-oncology guideline (PMID 36017575); AHA 2022 cardio-oncology scientific statement; Yeh & Bickford JACC 2009 cardiotoxicity in HSCT (PMID 19608050); Tichelli EBMT 2008 cardiac complications HSCT (PMID 18176622); ASTCT CMV management (PMID 20530287); REACH-2 NEJM 2020 (ruxolitinib for steroid-refractory acute GVHD)