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(Pathophysiology, Introduction and Epidemiology, Differential Diagnosis,…

- - - - Low cardiac index (<2.2 L/min/m2)
      - High systemic vascular resistance indices
      - Increased pulmonary capillary wedge pressure (LVEDP >15 mmHg)
      - Peripheral vasoconstriction and pulmonary edema
    - - Increased RV filling pressures
      - Decreased forward flow to LV resulting in lowered cardiac output
      - Lungs are spared
    - - Occurs subacutely in heart failure patients
    - - Rare
  - - - Acute mitral regurgitation secondary to papillary muscle dysfunction or chordal rupture
      - Ventricular septal defect
      - Free wall rupture
      - Right ventricular infarction
      - Acute aortic insufficiency (aortic dissection)
    - - Acute myocardial infarction
      - Sepsis
      - Myocarditis
      - Myocardial contusion
      - Cardiomyopathy
      - Medication toxicity (beta-blocker overdose, calcium channel-blocker overdose)
      - Unstable dysrhythmia
    - - Aortic stenosis
      - Hypertrophic cardiomyopathy
      - Mitral stenosis
      - Left atrial myxoma
      - Pericardial tamponade
- - - - Impaired ejection fraction
      - Extensive infarct (large myocellular leak)
      - Proximal left anterior descending coronary artery occlusion
      - Anterior myocardial infarction
      - Multivessel coronary artery disease
    - - Previous myocardial infarction
      - Congestive heart failure
      - Diabetes
- - - - Positive-pressure ventilation decreases preload and cardiac output, worsening hypotension
      - Give fluid bolus if no severe pulmonary congestion and RV infarct present
      - Consider push dose pressors before intubation
      - Keep end-expiratory pressures and tidal volumes as low as possible
  - - - Give crystalloid fluid boluses of 250 to 500 mL and reassess
    - - Use vasopressors or inotropes based on blood pressure
    - - Dobutamine
        
        Dose: 2-5 mcg/kg/min, titrate to 20 mcg/kg/min
        
        Inotrope and potential vasodilator; lowers blood pressure
        
        Use as single agent only if SBP >= 90 mmHg
        
        Avoid as sole agent if SBP <90 mmHg
        
        Attenuated response if patient is on beta-blockers
      - Dopamine
        
        Dose: 3-5 mcg/kg/min, titrate to 20-50 mcg/kg/min
        
        Inotrope and vasoconstrictor
        
        Increases LVEDP and heart rate; higher risk of dysrhythmia
      - Norepinephrine
        
        Dose: 2 mcg/min, titrate to response
        
        Vasoconstrictor and inotrope
        
        Preferred single agent over dopamine if SBP <70 mmHg
        
        Can combine with dobutamine
      - Epinephrine
        
        Dose: 0.1-0.5 mcg/kg/min
        
        Inotrope and vasoconstrictor
        
        Second-tier choice due to increased systemic acidosis, tachycardia, and dysrhythmias
      - Milrinone
        
        Dose: 0.5 mcg/kg/min
        
        Phosphodiesterase-3 inhibitor (inotrope and vasodilator)
        
        Lowers blood pressure; substitute for dobutamine if on beta-blockers
      - Phenylephrine
        
        Contraindicated because it increases afterload without augmenting contractility
- - - - Troponin may not be elevated upon initial presentation
    - - Identifies anemia contributing to ischemia
    - - Elevated due to hypoperfusion
    - - Identify end-organ dysfunction
    - - Normal level (<100 pg/mL) eliminates cardiogenic shock (except very early onset or isolated right heart failure)
      - Elevated level indicates LV dysfunction but does not diagnose cardiogenic shock
    - - Identify acute respiratory failure or CO2 retention
      - Quantify severity of acidosis (metabolic vs. respiratory components)
  - - - Identifies ischemia, STEMI, rhythm abnormalities, electrolyte issues, or drug toxicity
      - Right-sided ECG (leads V1 and V3R to V6R ST-elevation) identifies RV infarction with inferior MI
    - - Portable CXR shows pulmonary congestion, edema, alveolar infiltrates, pleural effusion
      - Radiographic findings may lag by hours
      - Cardiomegaly indicates long-standing remodeling
      - Rules out pneumonia, pneumothorax, aortic dissection, pericardial effusion
    - - IVC volume status and right atrial pressure estimation
      - Subcostal view: Pericardial effusion, tamponade (IVC dilation, RV diastolic collapse, RA systolic collapse), clot from cardiac rupture
      - Subcostal, parasternal, apical views: Estimate EF and contractility
      - Aortic root >3 cm: Concerns for ascending aortic dissection
      - Valve motion and flow assessment (mitral valve)
      - Apical 4-chamber view: Chamber size (RV dilated with small LV in acute right heart failure; LV dilated in left heart failure)
      - Lung POCUS: B-lines (3 B-lines in 2 bilateral lung zones) indicating interstitial edema
    - - Color and spectral Doppler identifies mechanical complications
      - Detects regional wall motion abnormalities and loss of compensatory hyperkinesis
      - Color flow Doppler identifies acute mitral regurgitation, VSD, or pulmonary embolism
    - - Immediate cardiothoracic surgery consultation
      - Free wall rupture: Death likely unless pseudoaneurysm forms (acute pericardial effusion)
      - VSD: Oxygen saturation step-up from RA to RV on right heart catheterization or Doppler
    - - Low cardiac index (<2.2 L/min/m2)
      - Elevated LVEDP (pulmonary artery occlusion pressure >15 mmHg)
      - Arterial line monitoring for accurate blood pressure during resuscitation
      - Noninvasive SBP may underestimate SBP by >30 mmHg (MAP varies by 1 to 2 mmHg)
      - Central venous pressure aids global volume assessment
- - - - Systolic blood pressure usually <90 mmHg (can be higher with prior hypertension or vasoconstriction)
      - Pulse pressure <20 mmHg
      - Sinus tachycardia common (unless on rate-blocking meds)
      - Tachypnea (until respiratory fatigue sets in)
    - - Pale or cyanotic
      - Cool skin and mottled extremities
      - Diaphoresis
      - Altered mental status from cerebral hypoperfusion
      - Low urine output from renal hypoperfusion
    - - Chest exam demonstrates rales from pulmonary edema
    - - Lungs are spared
      - Venous congestion (increased JVP)
      - Kussmaul sign (rise in JVP with inspiration)
      - Hepatojugular reflux
      - Enlarged liver and peripheral edema
      - Third heart sound (S3) originating from RV
    - - New or loud systolic murmurs
      - Acute Mitral Regurgitation: Soft holosystolic murmur at apex radiating to axilla
      - Acute Ventricular Septal Defect: New loud holosystolic left parasternal murmur with palpable thrill
      - Acute Aortic Insufficiency: Soft diastolic murmur and softer S1 sound