Management of severe heart failure and cardiogenic shock is difficult. There is a notable lack of high-quality evidence regarding the sickest patients. Treatment strategies validated among more stable patients may not be applicable to the most unstable heart failure patients.
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The IBCC chapter is located here.
- The podcast & comments are below.
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Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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Good morning Josh!
I just finished listening, and i was curious about the portion where you discussed using nitrates and hydralazine, as well as the concern for renal inpairment with ACE inhibitors. Does this concern also apply in the setting of sympathetic inducied APE? My understanding was that using IV ACE-I can assist in acute breaking the RAAS, which seems to be a co-conspirator in the pathology.
ACEi are nephrotoxic and this needs to be considered whenever they are used. High-dose nitroglycerine and high-pressure BiPAP are front-line therapies for SCAPE. If these don’t work and the patient remains hypertensive, then there is some evidence to support ACEi and that would be a reasonable consideration (in the absence of other risk factors for AKI). Generally ACEi aren’t needed though if you use enough nitroglycerine (e.g. up to ~250 mcg/min). Will explore this more in the chapter on SCAPE but that one might not be out for a while.
Im on board with the nitro doses. I myself have never needed to use anything more than nitro bipap, but i certainly dont want a failty next step. Cant wait for the episode!
Hello Dr. Farkas, I am a RN that works in a coronary ICU and we do see a good numbers of CS patients. We have IABP, Impella 2.5 and CP and we are in the process of getting Impella 5.0. I was recently at a conference in Boston on CS where many great minds in the field of cardiology presented great cases. Some of the great minds in field of cardiology have spoken on how Impella has shown superiority to IABP since Impella unloads LV decreasing ventricular wall resistance, decreases myocardial oxygen demand, reduces LVEDP and it effectively provides anywhere… Read more »
thanks! Will keep an eye on new evidence emerging on this topic.
Josh thanks for a great post as always. As far as the liver injury goes, is there a way to differentiate shock liver from congestive liver? And if so does the presence of one or the other signify worse severity?
Why Nitroglycerin over nitroprusside?
Hello.
I know levosimendan it’s not approved in US or Canada, But do you see any advantage in its use in cardiogenic shock? (either for palliative or not palliative treatment)
Hey Josh, a fantastic post I’ve returned to but had a question. Have not been able to find good resources for the management of patients with moderate to severe AS, heart failure and atrial fibrillation. These patients seem to be common in my ED and rapid response calls. BiPAP as always seems to be my agent of choice and I’ve always been cautious to use nitroglycerin with their fixed stenotic lesion in the severely hypertensive. I’m curious to your thoughts on nitroglycerin in the setting of AS and severe HTN and pulmonary oedema? Additionally curious about your rate control strategy… Read more »
Hello Dr Farkas
Would love to know your take on patients presenting with ADHF (either SCAPE or shock) with concomitant signs of sepsis .. NTG / diuresis vs fluid resuscitation
I know it is a broad topic but I’m seeing alot of these patients lately ..
Thanks for the great blog.