Patient handout

Cardiogenic shock — SCAI Stage D (deteriorating)

PRODUCTION

1. Your condition

This handout is for cardiogenic shock — scai stage d (deteriorating). Your care team identified this based on: sbp <90 / map <65 despite norepinephrine + dobutamine — scai d.

Other reasons your team may use this plan: lactate rising or static ≥2 mmol/l despite ≥6h initial therapy — failure to clear; new aki + transaminitis + altered mentation on first-line therapy — d-stage progression.

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 mcg/kg/min IV titrate to MAP ≥65	IV	continuous	SOAP-II PMID 20200382 — NE preferred over dopamine in CS; first-line per ACC/AHA 2022 + SCAI 2022
dobutamine	2.5 mcg/kg/min IV titrate	IV	continuous	First-line inotrope in CS per SCAI 2022; CI <2.2 + adequate filling pressure
vasopressin	0.03 U/min IV (fixed-dose adjunct)	IV	continuous	V1-mediated vasoconstriction spares pulmonary vasculature; adjunctive when NE >0.5 mcg/kg/min cannot maintain MAP — VANISH/VASST extrapolation
milrinone	0.125-0.375 mcg/kg/min IV (no bolus in CS)	IV	continuous	PDE3 inhibitor preferred when pulmonary HTN dominant; avoid bolus in CS (hypotension risk)
epoprostenol_inhaled	50 ng/kg/min nebulized	INH	continuous	Inhaled pulmonary vasodilator if RV strain develops on Impella support

Plan: SCAI D escalation regimen — adds MCS + second pressor to parent CS regimen

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent CS → readmit + escalate to chronic engine or hospice

4. When to seek emergency care

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

MAP <65 despite NE >0.5 mcg/kg/min + dobutamine ≥5 mcg/kg/min for ≥2h — D-stage hemodynamic floor(life-threatening)
Lactate rising or static ≥2 mmol/L for ≥6h despite resuscitation + first-line agents(life-threatening)
New Cr rise ≥0.3 mg/dL or oliguria <0.5 mL/kg/h × 6h on CS therapy — multi-organ involvement
Impella CP deployed but persistent MAP <65 + lactate not clearing → escalate to VA-ECMO(life-threatening)
Persistent multi-organ failure (SOFA increasing) at 24-72h despite max MCS + pharmacology — futility threshold(life-threatening)

5. Follow-up

If recovery: MCS wean, the four foundational heart-failure medications initiation, advanced HF clinic; if no recovery → SCAI E pathway

6. Sources

Guideline: SCAI 2022 CS staging + 2025 ACC/AHA ACS + 2022 ACC/AHA HF (with 2023 Focused Update)