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Hemodynamic goals in left-sided cardiogenic shock

Type of shock	Preload	Afterload	Rate	Rhythm	Contractility	Comments
LV myopathy with systolic dysfunction	↓	↓	↑	Sinus	↑	Dobutamine, milrinone, or a combination are ideal agents, unless severe active ischemia is present.
Acute mitral regurgitation	↓	↓	↑↑	Sinus	↑	Dobutamine, milrinone, or a combination are supportive ideal agents. IABP to be considered. Address the cause of the MR as soon as possible.
Acute aortic regurgitation	↓	↓↓	↑↑	Sinus	↑	Dobutamine, milrinone, or a combination are ideal agents until the cause of the AR can be addressed.
Aortic stenosis (AS)	←→	←→	70 to 90	Sinus	←→	Patients with critical AS do not tolerate tachycardia or bradycardia. Typically afterload reduction is not tolerated, although may be useful in end-stage disease with dilated LV.
Hypertrophic cardiomyopathy	↑	↑	↓	Sinus	↓	Inotropes are contraindicated. Fluid and phyenylephrine are the first line agents.
Diastolic dysfunction
Mild, relaxation abnormality	←→	←→	↓	Sinus	←→	Typically E/A ratio <1 and LV diastolic filling can be augmented by a slow HR.
Severe	↓	←→	↑↑	Sinus	←→	Typically E/A ratio >2 and severe LV stiffness limits filling. Stroke volume is fixed and CO is therefore rate dependent. Consider temporary atrial pacing if possible.
Moderate, pseudo-normalization	↓	←→	?	Sinus	←→	Some cases of pseudo-normalization behave more like restrictive physiology and require higher HR, whereas others behave more like a relaxation abnormality.

LV: left ventricle/left ventricular; IABP: intra-aortic balloon pump; MR: mitral regurgitation; AR: aortic regurgitation; CO: carbon monoxide; HR: heart rate; E: early mitral inflow velocity; A: late mitral inflow velocity resulting from atrial contraction.

Graphic 109868 Version 1.0