Patient handout

Cardiogenic shock — RV-predominant

PRODUCTION

1. Your condition

This handout is for cardiogenic shock — rv-predominant. Your care team identified this based on: rv-mi: st↑ v4r + proximal rca culprit on angio + clear lungs.

Other reasons your team may use this plan: massive pe: hemodynamic compromise + rv strain on pocus/ct; hemodynamic profile: elevated cvp + low pcwp + low pa pressure → rv-predominant.

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
sodium chloride 0.9%	250-500 mL IV bolus, reassess CVP + lung exam	IV	bolus + reassess	Preload optimization — RV is preload-dependent; bolus only if CVP <12-15 + clear lungs (Goldstein NEJM 1990)
norepinephrine	0.05-0.5 mcg/kg/min IV titrate	IV	continuous	NE preferred to maintain coronary perfusion to RV; SOAP-II PMID 20200382
dobutamine	2.5-5 mcg/kg/min IV (low-dose to avoid tachyarrhythmia)	IV	continuous	Inotrope for RV contractility; lower doses to avoid tachyarrhythmia
milrinone	0.125-0.375 mcg/kg/min IV (no bolus — hypotension risk)	IV	continuous	PDE3 inhibitor with pulmonary vasodilation — preferred when pulmonary HTN drives RV failure
epoprostenol_inhaled	50 ng/kg/min nebulized	INH	continuous	Selective pulmonary vasodilator; reduces RV afterload without systemic hypotension
nitric_oxide_inhaled	20-40 ppm INH	INH	continuous	Selective pulmonary vasodilator; first-line in pulm HTN crisis + post-CT-surgery RV failure
alteplase	100 mg IV over 2h (reduced dose 50 mg if bleed risk)	IV	one-time infusion	Massive PE with hemodynamic compromise — Class I per Konstantinides ESC PE 2019

Plan: RV-predominant CS regimen — preload + pulmonary vasodilator + RV-MCS (NOT isolated LV-MCS)

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent RV failure → readmit

4. When to seek emergency care

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

RV-MI + SBP <90 + clear lungs → preload optimization (250-500 mL crystalloid bolus)
Massive PE + SBP <90 sustained + RV strain on POCUS → systemic thrombolysis or catheter thrombectomy(life-threatening)
Isolated LV-MCS (Impella CP) considered in RV-predominant CS — STOP, will worsen RV by reducing LV filling
Pulmonary HTN crisis (mean PA >50) + RV failure → iNO 20-40 ppm + inhaled epoprostenol(life-threatening)
New LV failure superimposed on RV-CS (rising PCWP, pulmonary edema) → VA-ECMO(life-threatening)

5. Follow-up

If RV-MI: standard post-MI care + the four foundational heart-failure medications if EF reduced; if PE: long-term AC + post-PE syndrome screen; if pulm HTN: PH center referral

6. Sources

Guideline: SCAI 2022 CS staging + ESC PE 2019 (Konstantinides) + AHA 2022 HF