This handout is for cardiogenic shock — takotsubo (stress) cardiomyopathy. Your care team identified this based on: bedside echo: apical ballooning (or midventricular / basal / focal pattern) + lv dysfunction + shock physiology — takotsubo cardiomyopathy with cs.
Other reasons your team may use this plan: recent severe emotional (death of loved one, divorce) or physical (surgery, sepsis, severe illness) stressor in postmenopausal female (~90% predominance) presenting with shock; cath: no obstructive cad + lv gram showing apical ballooning + rwma crossing single coronary territory — intertak criteria (ghadri 2018); cardiac mri: regional wall motion abnormality + edema on t2 + absent lge (vs ischemic cmp) — confirms takotsubo.
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 | 0.03–0.2 µg/kg/min CAUTIOUS titration (lower than standard CS to avoid catecholamine excess) | IV | continuous; titrate to MAP ≥65 | SOAP-II PMID 20200382 — NE first-line in CS; in Takotsubo use lowest effective dose to avoid worsening catecholamine excess; preferred over inotropes |
| phenylephrine | 40–360 µg/min IV | IV | continuous | Pure α-agonist; preferred in LVOT-obstruction subtype because it raises afterload without inotropy (which worsens dynamic obstruction); ESC HFA 2016 Lyon position |
| esmolol | 500 µg/kg bolus then 50–200 µg/kg/min | IV | continuous, titrate | LVOT-obstruction Takotsubo subset (15–25%) — β-blocker reduces dynamic gradient and improves forward flow; esmolol short-acting allows rapid titration; AVOID in non-LVOT subtype |
| isotonic crystalloid (LR or NS) | 250–500 mL bolus | IV | reassess after each bolus | In LVOT-obstruction subtype, IV fluids increase LV cavity size and reduce dynamic gradient; AVOID in non-LVOT subtype with pulmonary edema |
| warfarin | 5 mg daily; INR target 2–3 | PO | daily × 3 mo | AHA 2022 Class IIa for LV thrombus (extrapolated); apical-ballooning Takotsubo carries mural-thrombus risk while LV remains dysfunctional; 3-mo course typically sufficient given recovery timeline |
| apixaban | 5 mg BID (or 2.5 mg BID per dose-reduction criteria) | PO | BID × 3 mo for mural thrombus prophylaxis | Off-label-but-rational DOAC alternative for LV thrombus prophylaxis; small RCTs support non-inferiority to warfarin in LV thrombus |
| sacubitril-valsartan | 24/26 BID (consider after recovery; debated indication) | PO | BID | No RCT-grade evidence in Takotsubo recovery; case-by-case consideration if persistent HFrEF beyond expected recovery window per Lyon 2016 ESC HFA position |
Plan: Takotsubo CS — subtype-aware support; AVOID inotropes / β-blocker (non-LVOT subtype); LVOT subtype requires β-blocker + fluids + phenylephrine; MCS for bridge to recovery
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 at 4–8 wks to confirm complete LV recovery (Templin NEJM 2015); psych follow-up; long-term ARNI / BB after recovery debated (no RCT-grade evidence — case-by-case); recurrence ~5–10% over follow-up — patient education on stressor-mitigation
Guideline: InterTAK consortium / Ghadri 2018 Eur Heart J expert consensus Part I + II; Templin NEJM 2015 PMID 26332547 (InterTAK registry); Lyon 2016 ESC HFA position statement on Takotsubo; ESC 2018 Takotsubo position paper