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cardio.cardiogenic-shock.rv-predominant.v1PRODUCTION
cardio.cardiogenic-shock.rv-predominant.v1

Cardiogenic shock — RV-predominant

cardiologyacuteadult
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10/12 authored

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

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Detailed

RV-predominant CS = low CO + elevated CVP + low/normal PCWP + low PA → preload-dependent + pulmonary-vasodilator-responsive

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RV-predominant phenotype confirmed

Patient inputs (6)

Hypotension despite fluid responsiveness defines RV-CS

Elevated CVP with low PCWP is the RV-predominant hemodynamic signature

RV dilation, RV/LV ratio >1, septal flattening (D-shape), McConnell sign for PE — defines RV failure

V4R for RV-MI; S1Q3T3 + RBBB for PE; ST↓ inferior + V1-V2 for posterior MI extension

Lactate trend for RV-CS perfusion adequacy

Angio for RV-MI culprit; CTPA for massive PE

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningmassive_pe_with_rv_failure
    Massive PE + SBP <90 sustained + RV strain on POCUS → systemic thrombolysis or catheter thrombectomy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpulm_htn_crisis_with_rv_failure
    Pulmonary HTN crisis (mean PA >50) + RV failure → iNO 20-40 ppm + inhaled epoprostenol
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbiventricular_failure_progression
    New LV failure superimposed on RV-CS (rising PCWP, pulmonary edema) → VA-ECMO
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererv_mi_with_hypotension_responsive_to_fluid
    RV-MI + SBP <90 + clear lungs → preload optimization (250-500 mL crystalloid bolus)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereavoid_lv_mcs_in_rv_predominant_cs
    Isolated LV-MCS (Impella CP) considered in RV-predominant CS — STOP, will worsen RV by reducing LV filling
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

RV-predominant CS regimen — preload + pulmonary vasodilator + RV-MCS (NOT isolated LV-MCS)
axis: rv_predominant_phenotype
Selected axis "RV-predominant CS regimen — preload + pulmonary vasodilator + RV-MCS (NOT isolated LV-MCS)" by default fallback (first axis)
  • sodium chloride 0.9%
    first line
    crystalloid
    250-500 mL IV bolus, reassess CVP + lung exam • IV • bolus + reassess
    triggers: rv_cs_with_low_to_normal_cvp
    Preload optimization — RV is preload-dependent; bolus only if CVP <12-15 + clear lungs (Goldstein NEJM 1990)
    rxcui 9863
  • norepinephrine
    first line
    alpha_beta_agonist_pressor
    0.05-0.5 mcg/kg/min IV titrate • IV • continuous
    triggers: rv_cs_with_persistent_hypotension_after_preload
    NE preferred to maintain coronary perfusion to RV; SOAP-II PMID 20200382
    rxcui 7512
  • dobutamine
    first line
    beta1_agonist_inotrope
    2.5-5 mcg/kg/min IV (low-dose to avoid tachyarrhythmia) • IV • continuous
    triggers: rv_cs_with_low_ci
    Inotrope for RV contractility; lower doses to avoid tachyarrhythmia
    rxcui 3616
  • milrinone
    second line
    pde3_inhibitor_inotrope
    0.125-0.375 mcg/kg/min IV (no bolus — hypotension risk) • IV • continuous
    triggers: rv_cs_with_pulm_htn_dominant
    PDE3 inhibitor with pulmonary vasodilation — preferred when pulmonary HTN drives RV failure
    rxcui 52769
  • epoprostenol_inhaled
    first line
    pulmonary_vasodilator
    50 ng/kg/min nebulized • INH • continuous
    triggers: rv_cs_with_pulm_htn, rv_cs_with_severe_rv_strain
    Selective pulmonary vasodilator; reduces RV afterload without systemic hypotension
    rxcui 8814
  • nitric_oxide_inhaled
    first line
    pulmonary_vasodilator
    20-40 ppm INH • INH • continuous
    triggers: rv_cs_with_pulm_htn, rv_cs_post_cardiac_surgery
    Selective pulmonary vasodilator; first-line in pulm HTN crisis + post-CT-surgery RV failure
    rxcui 7442
  • alteplase
    first line
    thrombolytic
    100 mg IV over 2h (reduced dose 50 mg if bleed risk) • IV • one-time infusion
    triggers: massive_pe_with_rv_failure
    Massive PE with hemodynamic compromise — Class I per Konstantinides ESC PE 2019
    rxcui 8410

outpatient playbook — drug actions (1)

  1. 1. continue AC if PE
    rxcui 1037045
    apixaban 5 mg BID indefinite if unprovoked PE • PO • BID
    trigger: PE etiology
    AMPLIFY-EXT

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: RV-MI: ST↑ V4R + proximal RCA culprit on angio + clear lungs; Massive PE: hemodynamic compromise + RV strain on POCUS/CT; Hemodynamic profile: elevated CVP + low PCWP + low PA pressure → RV-predominant.

Objective

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

Assessment

**Cardiogenic shock — RV-predominant** (cardio.cardiogenic-shock.rv-predominant.v1).
Scope: RV-predominant CS = low CO + elevated CVP + low/normal PCWP + low PA → preload-dependent + pulmonary-vasodilator-responsive

No severity triggers fired against current inputs.

Plan

Regimen axis: **RV-predominant CS regimen — preload + pulmonary vasodilator + RV-MCS (NOT isolated LV-MCS)**.
1. sodium chloride 0.9% 250-500 mL IV bolus, reassess CVP + lung exam IV bolus + reassess (crystalloid, first line) — Preload optimization — RV is preload-dependent; bolus only if CVP <12-15 + clear lungs (Goldstein NEJM 1990)
2. norepinephrine 0.05-0.5 mcg/kg/min IV titrate IV continuous (alpha_beta_agonist_pressor, first line) — NE preferred to maintain coronary perfusion to RV; SOAP-II PMID 20200382
3. dobutamine 2.5-5 mcg/kg/min IV (low-dose to avoid tachyarrhythmia) IV continuous (beta1_agonist_inotrope, first line) — Inotrope for RV contractility; lower doses to avoid tachyarrhythmia
4. milrinone 0.125-0.375 mcg/kg/min IV (no bolus — hypotension risk) IV continuous (pde3_inhibitor_inotrope, second line) — PDE3 inhibitor with pulmonary vasodilation — preferred when pulmonary HTN drives RV failure
5. epoprostenol_inhaled 50 ng/kg/min nebulized INH continuous (pulmonary_vasodilator, first line) — Selective pulmonary vasodilator; reduces RV afterload without systemic hypotension
6. nitric_oxide_inhaled 20-40 ppm INH INH continuous (pulmonary_vasodilator, first line) — Selective pulmonary vasodilator; first-line in pulm HTN crisis + post-CT-surgery RV failure
7. alteplase 100 mg IV over 2h (reduced dose 50 mg if bleed risk) IV one-time infusion (thrombolytic, first line) — Massive PE with hemodynamic compromise — Class I per Konstantinides ESC PE 2019

Setting playbook (outpatient) — Long-term: PE post-thrombotic syndrome screen, RV-MI surveillance, PH chronic management if applicable
8. continue AC if PE apixaban 5 mg BID indefinite if unprovoked PE PO BID — PE etiology (AMPLIFY-EXT)

Non-pharmacologic actions:
- PH center maintenance
- Cardiac rehab maintenance phase

AVOID / contraindication checks:
- Avoid_isolated_lv_mcs_in_rv_predominant_cs (Impella CP worsens RV by reducing LV filling)
- Avoid_aggressive_diuresis_in_rv_cs (reduces preload critical for RV CO)
- Nitroglycerin_avoid_in_rv_mi (preload reduction precipitates shock)
- Thrombolytics_absolute_ci_recent_stroke_active_bleeding (massive PE protocol)

Monitoring

Regimen monitoring:
- pa catheter for cvp pcwp pa pressure (RV signature)
- echo q24h for rv lv ratio and septal d sign (RV recovery marker)
- lactate q1h x 6h then q4h (perfusion clearance)
- urine output q1h (perfusion marker)

Setting (outpatient) monitoring:
- Quarterly NT-proBNP
- Annual echo

Follow-up plan: If RV-MI: standard post-MI care + GDMT if EF reduced; if PE: long-term AC + post-PE syndrome screen; if pulm HTN: PH center referral
- Close-out criterion: etiology-specific follow-up plan booked

Monitoring phase: Continuous CVP + PA pressure + CO; q1h lactate × 6h; RV/LV ratio on echo daily

Disposition

Current setting: outpatient — Long-term: PE post-thrombotic syndrome screen, RV-MI surveillance, PH chronic management if applicable

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 or pulm.pulmonary_htn engine

Escalation triggers (move to higher acuity):
- Recurrent RV failure → readmit

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Massive PE + SBP <90 sustained + RV strain on POCUS → systemic thrombolysis or catheter thrombectomy
- [LIFE_THREATENING] 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

Citations

- SCAI 2022 CS staging + ESC PE 2019 (Konstantinides) + AHA 2022 HF [PMID:35115207](https://pubmed.ncbi.nlm.nih.gov/35115207/)
- Cited evidence (PMID 19237899) [PMID:19237899](https://pubmed.ncbi.nlm.nih.gov/19237899/)
- Cited evidence (PMID 38587239) [PMID:38587239](https://pubmed.ncbi.nlm.nih.gov/38587239/)
- Cited evidence (PMID 37634145) [PMID:37634145](https://pubmed.ncbi.nlm.nih.gov/37634145/)
- Cited evidence (PMID 25820680) [PMID:25820680](https://pubmed.ncbi.nlm.nih.gov/25820680/)

Last reconciled with current guidelines: 2026-05-14.
References