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. |
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