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cardio.cardiogenic-shock.pe-related.v1PRODUCTION
cardio.cardiogenic-shock.pe-related.v1

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

cardiologyacuteadult
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11/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Detailed

Massive PE causing obstructive + cardiogenic physiology; RV pump failure is the proximate killer; thrombolysis is the upstream fix; route through this engine for hemodynamic management while pulm.pe.core.v1 owns the AC + thrombolysis decision

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Massive PE with shock confirmed

Patient inputs (9)

Tachycardia >110 + sustained hypotension drives shock-trigger threshold

eGFR for contrast (CTPA), DOAC dosing post-discharge

Bleed-risk + thrombolysis contraindication screen (active bleeding, recent intracranial surgery, recent stroke <3 mo)

Bedside echo for McConnell sign, RV/LV ratio >1, septal flattening (D-sign), dilated IVC — defines RV failure and obstructive physiology

CTPA confirms PE + clot burden + saddle vs proximal vs subsegmental; only obtain if hemodynamically tolerable, otherwise treat empirically

RV strain marker + risk stratification (PESI / Bova score); positive troponin upgrades to high-risk PE

Elevated BNP/NT-proBNP indicates RV strain in PE (ESC 2019)

Sustained SBP <90 for ≥15 min defines massive (high-risk) PE per ESC 2019 (Konstantinides PMID 31504429)

Lactate ≥2 marks SCAI Stage C+ shock physiology

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningmassive_pe_with_cardiac_arrest_pending
    PE with hemodynamic collapse + cardiac arrest imminent → empiric reduced-dose alteplase 50 mg IV push
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmassive_pe_with_thrombolysis_contraindication
    Massive PE + absolute thrombolysis CI (recent ICH, neoplasm, surgery <2 wk) → surgical embolectomy or catheter thrombectomy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpersistent_shock_despite_thrombolysis
    No hemodynamic improvement at 1-2h post-systemic alteplase → escalate to VA-ECMO bridge
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_lysis_intracranial_hemorrhage
    New neurological deficit or AMS post-thrombolysis → STAT non-contrast CT head + reverse
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereavoid_lv_only_mcs_in_pe_related_cs
    Isolated LV-MCS (Impella CP) considered in PE-related CS — STOP, will worsen RV by reducing LV filling and septal interaction
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

PE-related cardiogenic shock — systemic thrombolysis + RV-supporting pressors + pulmonary vasodilation; AVOID LV-only MCS
axis: pe_related_cs_phenotype
Selected axis "PE-related cardiogenic shock — systemic thrombolysis + RV-supporting pressors + pulmonary vasodilation; AVOID LV-only MCS" by default fallback (first axis)
  • alteplase
    first line
    thrombolytic_tpa
    100 mg IV over 2h (or 50 mg IV push if cardiac arrest) • IV • one-time infusion
    triggers: massive_pe_with_hemodynamic_compromise, no_absolute_thrombolysis_contraindication
    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
    rxcui 8410
  • unfractionated heparin
    first line
    anticoagulant_heparin
    80 U/kg IV bolus → 18 U/kg/h infusion, aPTT 1.5-2.5x • IV • continuous
    triggers: confirmed_pe, pre_thrombolysis_setup
    Bridges to thrombolysis or post-lysis AC; allows rapid reversal if bleeding develops
    rxcui 5224
  • norepinephrine
    first line
    alpha_beta_pressor
    0.05-0.5 mcg/kg/min IV titrate to MAP ≥65 • IV • continuous
    triggers: pe_cs_with_persistent_hypotension
    NE preferred — maintains coronary perfusion to failing RV; SOAP-II PMID 20200382
    rxcui 7512
  • dobutamine
    first line
    beta1_inotrope
    2.5-5 mcg/kg/min IV (low-dose to avoid tachyarrhythmia) • IV • continuous
    triggers: pe_cs_with_low_ci_after_pressor
    RV inotropic support; titrate cautiously to avoid pulmonary vasodilator-driven systemic hypotension and tachyarrhythmia
    rxcui 3616
  • nitric oxide inhaled
    first line
    pulmonary_vasodilator
    20-40 ppm INH • INH • continuous
    triggers: pe_cs_with_pulmonary_htn_dominant, rv_strain_after_thrombolysis
    Selective pulmonary vasodilator — reduces RV afterload without systemic hypotension; bridge to clot resolution
    rxcui 7442
  • epoprostenol inhaled
    first line
    pulmonary_vasodilator
    50 ng/kg/min nebulized • INH • continuous
    triggers: pe_cs_with_persistent_pulmonary_htn, inhaled_no_unavailable
    Adjunct selective pulmonary vasodilator (often used when iNO unavailable or insufficient)
    rxcui 8814
  • apixaban
    first line
    doac_factor_xa_direct
    10 mg BID × 7d → 5 mg BID × ≥6 mo (post-stabilization) • PO • BID
    triggers: post_stabilization_oral_ac_transition
    AMPLIFY DOAC strategy for PE; preferred over warfarin per ESC 2019
    rxcui 1364430

outpatient playbook — drug actions (1)

  1. 1. continue apixaban indefinite if unprovoked PE
    rxcui 1037045
    5 mg BID (or 2.5 mg BID after 6 mo per AMPLIFY-EXT) • PO • BID
    trigger: Unprovoked PE + low bleed risk
    AMPLIFY-EXT — 2.5 mg BID extended-phase non-inferior to 5 mg BID with lower bleeding

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Massive PE on CTPA + RV/LV ratio >1 + septal flattening on bedside echo; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — PE-related (massive PE with RV failure)** (cardio.cardiogenic-shock.pe-related.v1).
Scope: Massive PE causing obstructive + cardiogenic physiology; RV pump failure is the proximate killer; thrombolysis is the upstream fix; route through this engine for hemodynamic management while pulm.pe.core.v1 owns the AC + thrombolysis decision

No severity triggers fired against current inputs.

Plan

Regimen axis: **PE-related cardiogenic shock — systemic thrombolysis + RV-supporting pressors + pulmonary vasodilation; AVOID LV-only MCS**.
1. alteplase 100 mg IV over 2h (or 50 mg IV push if cardiac arrest) IV one-time infusion (thrombolytic_tpa, first line) — 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
2. unfractionated heparin 80 U/kg IV bolus → 18 U/kg/h infusion, aPTT 1.5-2.5x IV continuous (anticoagulant_heparin, first line) — Bridges to thrombolysis or post-lysis AC; allows rapid reversal if bleeding develops
3. norepinephrine 0.05-0.5 mcg/kg/min IV titrate to MAP ≥65 IV continuous (alpha_beta_pressor, first line) — NE preferred — maintains coronary perfusion to failing RV; SOAP-II PMID 20200382
4. dobutamine 2.5-5 mcg/kg/min IV (low-dose to avoid tachyarrhythmia) IV continuous (beta1_inotrope, first line) — RV inotropic support; titrate cautiously to avoid pulmonary vasodilator-driven systemic hypotension and tachyarrhythmia
5. nitric oxide inhaled 20-40 ppm INH INH continuous (pulmonary_vasodilator, first line) — Selective pulmonary vasodilator — reduces RV afterload without systemic hypotension; bridge to clot resolution
6. epoprostenol inhaled 50 ng/kg/min nebulized INH continuous (pulmonary_vasodilator, first line) — Adjunct selective pulmonary vasodilator (often used when iNO unavailable or insufficient)
7. apixaban 10 mg BID × 7d → 5 mg BID × ≥6 mo (post-stabilization) PO BID (doac_factor_xa_direct, first line) — AMPLIFY DOAC strategy for PE; preferred over warfarin per ESC 2019

Setting playbook (outpatient) — Long-term AC management (≥6 mo or indefinite if unprovoked); CTEPH surveillance at 3-6 mo; thrombophilia counseling; family screening if hereditary
8. continue apixaban indefinite if unprovoked PE 5 mg BID (or 2.5 mg BID after 6 mo per AMPLIFY-EXT) PO BID — Unprovoked PE + low bleed risk (AMPLIFY-EXT — 2.5 mg BID extended-phase non-inferior to 5 mg BID with lower bleeding)

Non-pharmacologic actions:
- PH center referral if CTEPH confirmed (riociguat or BPA candidates)
- Genetic counseling if thrombophilia identified
- Annual influenza + COVID + pneumococcal vaccinations

AVOID / contraindication checks:
- Thrombolytics_absolute_ci_recent_intracranial_surgery_or_neoplasm (ESC 2019)
- Thrombolytics_absolute_ci_active_bleeding_or_recent_stroke_3mo (ESC 2019)
- Avoid_isolated_lv_mcs_in_rv_failure (Impella CP worsens RV by reducing LV filling and septal interaction)
- Nitroglycerin_avoid_in_rv_failure (preload reduction precipitates shock)
- Avoid_aggressive_diuresis_in_rv_failure (preload dependent physiology)
- Fluid_bolus_caution_in_pe_cs (overdistension worsens RV; use only if CVP <8 10 with clear preload deficit)
- Vasopressin_avoid_in_pulmonary_htn (V1 effect worsens PVR)

Monitoring

Regimen monitoring:
- continuous arterial line BP (ESC 2019)
- lactate q1h x 6h then q4h (CardShock perfusion clearance)
- serial echo q12-24h for rv recovery (RV/LV ratio, septal D-sign resolution)
- coag panel q6h x 24h post lysis (fibrinogen, PT/INR, aPTT, platelets)
- neuro check q1h x 24h post lysis (intracranial hemorrhage screen)
- urine output q1h (perfusion marker)

Setting (outpatient) monitoring:
- Annual cardiology + pulm visits
- Annual echo if residual dysfunction

Follow-up plan: 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
- Close-out criterion: Long-term AC + post-PE plan booked

Monitoring phase: Continuous BP + SpO2 + telemetry; lactate q1h × 6h then q4h; serial echo for RV recovery (RV/LV ratio, septal D-sign resolution); coag panel q6h post-lysis × 24h

Disposition

Current setting: outpatient — Long-term AC management (≥6 mo or indefinite if unprovoked); CTEPH surveillance at 3-6 mo; thrombophilia counseling; family screening if hereditary

Disposition criteria:
- Long-term continuation; cross-link to pulm.pe.core.v1 for chronic AC + cardio.idiopathic-pulmonary-arterial-hypertension.v1 if CTEPH evolves

Escalation triggers (move to higher acuity):
- Recurrent VTE → escalate to lifelong AC + reassess for malignancy/thrombophilia
- CTEPH confirmed → pulmonary endarterectomy or balloon pulmonary angioplasty referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] No hemodynamic improvement at 1-2h post-systemic alteplase → escalate to VA-ECMO bridge

Citations

- 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) [PMID:31504429](https://pubmed.ncbi.nlm.nih.gov/31504429/)
- Cited evidence (PMID 24716683) [PMID:24716683](https://pubmed.ncbi.nlm.nih.gov/24716683/)
- Cited evidence (PMID 23241399) [PMID:23241399](https://pubmed.ncbi.nlm.nih.gov/23241399/)
- Cited evidence (PMID 20200382) [PMID:20200382](https://pubmed.ncbi.nlm.nih.gov/20200382/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 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) — PMID:31504429
  • Cited evidence (PMID 24716683) — PMID:24716683
  • Cited evidence (PMID 23241399) — PMID:23241399
  • Cited evidence (PMID 20200382) — PMID:20200382
  • Cited evidence (PMID 35718438) — PMID:35718438