acute decompensated heart failure - …unmfm.pbworks.com/w/file/fetch/46189116/acute...acute...
TRANSCRIPT
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ACUTE DECOMPENSATED HEART FAILURE : 2010 HFSA GUIDELINES
BART COX, M.D., FACC ASSOCIATE PROFESSOR OF MEDICINE
UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE DIRECTOR, ADVANCED HEART FAILURE PROGRAM
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DISCLOSURES
NONE
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OBJECTIVES
• UNDERSTAND THE DEFINITION OF ADHF • UNDERSTAND THE 4 HEMODYNAMIC
PROFILES AND HOW TO CORRELATE THERAPY TO EACH PROFILE
• UNDERSTAND METHODS OF DECONGESTION • UNDERSTAND THE USE OF IV VASODILATORS
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2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES
• JOURNAL OF CARDIAC FAILURE 2010; 16:475-539 (EXECUTIVE SUMMARY)
• JOURNAL OF CARDIAC FAILURE 2010; 16: e1-e194 (COMPLETE GUIDELINE)
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ACUTE DECOMPENSATED HEART FAILURE (ADHF): DEFINITION
• JACOBELLIS V. OHIO (1964) AND SUPREME COURT JUSTICE POTTER STEWART
• NEW ONSET OR GRADUAL OR RAPIDLY WORSENING HEART FAILURE SIGNS OR SYMPTOMS REQUIRING URGENT THERAPY.
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HEART FAILURE STATISTICS
• >5.5 MILLION HF PATIENTS IN USA • >650,000 NEW HF CASES ANNUALLY • ANNUAL US COST OF HF IN 2010 (DIRECT AND
INDIRECT): $39.2 BILLION • 1 YEAR MORTALITY IS 20% • 5 YEAR MOTALITY IS HIGH AND WORSE FOR
MALES – MALES: 59% – FEMALE: 45%
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ADHF STATISTICS
• 1 MILLION ADHF HOSPTIAL ADMISSIONS ANNUALLY
• ANOTHER 2 MILLION ANNUAL ADMISSIONS IN WHICH HF COMPLICATED THE PRIMARY DIAGNOSIS
• 30-50% OF PATIENTS DISCHARGED WITH ADHF WILL BE READMITTED WITHIN 3-6 MONTHS
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ADHF STATISTICS
• 50% OF ADHF ADMISSIONS HAVE LVEF > 40% • 50% OF ADHF ADMISSIONS HAVE LVEF < 40% • AVERAGE PATIENT ADMITTED WITH ADHF IS
75 YEARS OF AGE WITH SUBSTANTIAL COMORBIDITIES
• MOST COMMON CAUSE OF ADHF HOSPITALIZATION IS EXACERBATION OF CHRONIC HEART FAILURE
• IN HOSPITAL MORTALITY: 4%
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6 SLIDES OF BAD MEMORIES
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INTRODUCTION TO FILLING PRESSURES
• VENTRICULAR FILLING PRESSURE: THE PRESSURE IN THE VENTRICLE AT THE END OF DIASTOLE
• LEFT VENTRICULAR FILLING PRESSURE = PCWP, MEAN LA PRESSURE, LVEDP
• RIGHT VENTRICULAR FILLING PRESSURE= CVP, MEAN RA PRESSURE, RVEDP
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INTRODUCTION TO FILLING PRESSURES
• CONGESTION= SALT AND WATER RETENTION; FLUID OVERLOAD;
• TO RELIEVE CONGESTION IN ADHF PATIENTS, DECREASE FILLING PRESSURES
• TO DECREASE FILLING PRESSURES, DIURESE (OR ULTRAFILTRATE) AND VASODILATE
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FILLING PRESSURE IS THE PRESSURE AT THE END OF DIASTOLE
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INTRODUCTION TO PERFUSION IN ADHF
• IN ADHF, PERFUSION IS A FUNCTION OF CARDIAC OUTPUT
• CARDIAC OUTPUT= HR X STROKE VOLUME (SV) • STROKE VOLUME IS DEPENDENT UPON:
– PRELOAD: THE AMOUNT OF BLOOD IN THE VENTRICLE AT THE END OF DIASTOLE
– CONTRACTILITY OF THE VENTRICLE – AFTERLOAD: RESISTANCE TO VENTRICULAR EMPTYING
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INTRODUCTION TO PERFUSION IN ADHF
• TO IMPROVE CARDIAC OUTPUT: – OPTIMIZE RATE AND RHYTHM (ELIMINATE
BRADYCARDIA, TACHYCARDIA, AV DISSOCIATION) – OPTIMIZE PRELOAD (VENTRICLE NEITHER TOO
FULL NOR TOO EMPTY) – IMPROVE CONTRACTILITY – DECREASE AFTERLOAD (DILATE RESISTANCE
VESSELS)
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INTRODUCTION TO PERFUSION IIN ADHF
• CARDIAC INDEX = CARDIAC OUPUT / BSA • TO IMPROVE PERFUSION, IMPROVE CARDIAC
OUTPUT (OR INDEX)
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THE FOUR HEMODYNAMIC PROFILES
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RECOGNIZING THE FOUR HEMODYNAMIC PROFILES
• NO CONGESTION = DRY • CONGESTION= WET • NORMAL PERFUSION=WARM • DIMINISHED PERFUSION=COLD
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PROFILES AND HEMODYNAMICS
• DRY= PCWP < 18 AND RA PRESSURE < 8 • WET = PCWP > 18 OR RA PRESSURE > 8 • WARM= CARDIAC INDEX> 2.2 • COLD= CARDIAC INDEX < 2.2
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RECOGNIZING THE FOUR HEMODYNAMIC PROFILES
• 2 COMPONENTS OF DECOMPENSATED HEART FAILURE – ELEVATED FILLING PRESSURES (MOST COMMON) – REDUCED CARDIAC INDEX (RARE)
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2 MINUTE ASSESSMENT AND THE 4 HEMODYNAMIC PROFILES
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PRINCIPLES OF THERAPY IN A CONGESTED PATIENT: DECREASE THE
FILLING PRESSURES • RELIEVE CONGESTION BY REDUCING FILLING
PRESSURES • ABSENT CRITICAL ORGAN HYPOPERFUSION
THAT LIMITS REDUCING THE FILLNG PRESURES, IMPROVING CARDIAC INDEX DOES NOT WORK!!!!
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PRINCIPLES OF THERAPY: THE OPTIMAL FILLING PRESSURE
• OPTIMAL PCWP IS < 15-16 mm Hg; RA <8 – LOWERING FILLNG PRESSURES -> IMPROVED SV
• WHAT’S WRONG WITH ELEVATED FILLNGPRESSURES? – RESPONSIBLE FOR CONGESTIVE SYMPTOMS – ACTIVATE NEUROHORMONES (RAS, SNS) – INCREASE VALVULAR REGURGITATION – RESPONSIBLE FOR PULMONARY HTN – CAUSES RIGHT VENTRICULAR DYSFUNCTION – CAUSES ABNORMAL LV FILLNG PATTERNS
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FILLING PRESSURES AND STROKE VOLUME (SV)
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STROKE VOLUME IMPROVED BY DECREASING MITRAL REGURGITATION
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Warm and dry
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Warm and wet
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PROFILE B: WET AND WARM
• MOST PATIENTS PRESENTING WITH ADHF ARE PROFILE B
• GOAL OF TX: SX IMPROVEMENT BY REDUCTION OF FILLING PRESSURES
• FOR MAJORITY, IV DIURETIC TX IS THE MAIN INTERVENTION – MAY NEED TO ADD 2.5-10 mg METOLAZONE PO
OR CHLORTHIAZIDE 500-1000 mg IV
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PROFILE B: ROLE FOR ADJUNCTIVE AGENTS
• USE OF ADJUNCTIVE THERAPIES BEYOND DIURETICS HAS NOT BEEN DEMONSTRATED TO IMPROVE OUTCOMES IN HOSPITALIZED ADHF PATIENTS WITH PROFILE B – INOTROPES: ISCHEMIA/ARRHYTHMIAS/ DEATH – NESIRITIDE: EXPENSIVE PLACEBO – ENDOTHELIN ANTAGONIST: NO IMPROVEMENT – VASOPRESSIN ANTAGONIST: NO SUSTAINED
BENEFIT
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PROFILE B: VERY HIGH OR VERY LOW SYSTEMIC VASCULAR RESISTANCE
(SVR) • VERY HIGH SVR= > 1500 dyne/sec/cm-5 • HOW TO RECOGNIZE HIGH SVR:
– HIGH BP – VERY NARROW PULSE PRESSURE – PA CATHETER MEASUREMENT
• VERY LOW SVR (WITHOUT MEDS)= LOW BP + REASONABLE PULSE PRESSURE + WARM EXTREMITIES
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PROFILE C: COLD AND WET
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PROFILE C: COLD AND WET
• < 3% OF PATIENTS PRESENT WITH CARDIOGENIC SHOCK
• WET = CONGESTION (PCWP>18) • COLD = INADEQUATE PERFUSION (CI<2.2) • TX: YOU MAY NEED TO WARM THEM UP BEFORE
DRYING THEM OUT – DIURESIS WILL IMPROVE CARDIAC OUTPUT – DIURESIS MAY NOT BE POSSIBLE IF RENAL PERFUSION
IS SEVERELY IMPAIRED – WHAT TO USE: VASODILATOR OR INOTROPE?
• CHECK THE SVR AND LOOK AT THE BLOOD PRESSURE
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PROFILE C: IV VASODILATORS OR INOTROPES?
• CHOICE OF THERAPY DEPENDS ON SYSTEMIC
VASCULAR RESISTANCE AND BP • IF SVR IS HIGH, CHECK THE SBP
– SBP>85mm Hg: VASODILATOR – SBP<85 mm Hg: INOTROPE + IABP (INTRAORTIC
BALLOON PUMP)
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PROFILE L: COLD AND DRY
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PROFILE L: COLD AND DRY
• EXTREMELY RARE PRESENTATION • REQUIRES PA CATHETER PLACEMENT TO
EVALUATE FILLING PRESSURE – PCWP<12 AND RA<6: DC DIURETICS, PO FLUIDS – PCWP >16: PROFILE C – PCWP 12-16 + RA PRESSURE NORMAL:
• VASODILATORS , IABP, AND INOTROPE ARE TEMPORARY FIX
• NEEDS VAD/ TRANSPLANT EVALUATION
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DIURETICS
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HFSA GUIDELINE: HOW TO DIURESE
• DIURESE WITH IV LOOP DIURETIC • ULTRAFILTRATION MY BE USED IN LIEU OF IV
DIURETICS • DIURESE UNTIL DRY • DIURESE AT THE CORRECT RATE
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THE DOSE TRIAL: BOLUS OR INFUSION, LOW DOSE OR HIGH
DOSE?
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Kaplan–Meier Curves for the Clinical Composite End Point of Death, Rehospitalization, or Emergency Department Visit .
Felker GM et al. N Engl J Med 2011;364:797-805
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HFSA GUIDELINES: WHAT TO MONITOR DAILY DURING IV DIURESIS
• MONITORING OF INTAKE & OUTPUT AND DAILY WEIGHT IS RECOMMENDED TO ASSESS CLINICAL EFFICACY OF DIURETIC THERAPY – ROUTINE USE OF A FOLEY CATHETER IS NOT
RECOMMENDED FOR MONITORING VOLUME STATUS
• OBSERVE FOR DEVELOPMENT OF DIURETIC-INDUCED SIDE EFFECTS
• DAILY Na, K, Mg, RENAL FUNCTION, AND ORTHOSTATIC VITALS
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HEISENBERG’S UNCERTAINTY PRINCIPLE
• REGARDING SUBATOMIC PARTICLES, YOU MAY KNOW THE EXACT POSITION OR THE EXACT VELOCITY BUT YOU CAN NEVER KNOW
SIMULTANEOUSLY THE EXACT POSITION AND THE EXACT VELOCITY
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COX’S UNCERTAINTY PRINCIPLE
• YOU MAY HAVE AN ACCURATE DAILY WEIGHT, OR YOU CAN HAVE AN ACCURATE DAILY INTAKE AND OUTPUT, BUT YOU WILL NEVER
SIMULTANEOUSLY HAVE AN ACCURATE INTAKE AND OUTPUT AND WEIGHT
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DIURETIC SIDE EFFECTS • ELECTROLYTE ABNORMALITEIS
– HYPOKALEMIA – HYPOMAGNESEMIA – HYPONATREMIA
• HYPOTENSION • GOUT EXACERBATION • HEARING LOSS (RARE) • INCREASED INCIDENCE OF DIGOXIN TOXICITY • RENAL INSUFFICIENCY • MUSCLE CRAMPS ARE USUALLY DUE TO OVERLY RAPID
DIURESIS
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HFSA GUIDELINES: VOLUME OVERLOAD, RENAL DYSFUNCTION,
AND DIURETIC USE • PATIENTS WITH MODERATE – SEVERE RENAL
DYSFUNCTION AND EVIDENCE OF FLUID RETENTION SHOULD CONTINUE TO BE TREATED WITH DIURETICS
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CARDIORENAL SYNDROME: OUTDATED AND INCOMPLETE EXPLANATION
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CARDIORENAL SYNDROME: THE CURRENT EXPLANATION
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HFSA GUIDELINES: DESTROYING DIURETIC RESISTANCE
• DIAGNOSE IT: ARE THEY TRULY WET? • DECREASE THE Na AND FLUID INTAKE • DOSE IT: INCREASE DOSE OF DIURETIC • DRIP IT: FUROSEMIDE DRIP AT 5-20 mg/hr • DOUBLE THE SITE OF ACTION : ADD 5-10 mg
po METOLAZONE OR IV CHLORTHIAZIDE 500-1000 mg
• DEVICE IT: AQUAPHERESIS/ ULTRAFILTRATION
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THE DIET AND FLUID RESTRICTION
• 2 GRAM SODIUM DIET
• 2 LITER/DAY FLUID RESTRICTON
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WHAT ABOUT HYPONATREMIA
• SODIUM < 137 mEq/L ASSOCIATED WITH PROLONGED HOSPITALIZATION AND INCREASED IN-HOSPITAL MORTALITY – IN GENERAL, HYPONATREMIA IS ASSOICIATED
WITH DEATH, HIGH REHOSPITALIZATION, LONGER HOSPITAL STAYS, NEUROCOGNITIVE CHANGES, AND RENAL/HEPATIC DYSFUNCTION
• MOST HYPONATREMIC PATEIENTS WITH ADHF ARE VOLUME OVERLOADED
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WHAT ABOUT HYPONATREMIA?
• ETIOLOGY: INABILITY TO EXCRETE FREE H20 PRIMARILY DUE TO NEUROHORMONAL ACTIVATION – NOREPI, ANGIOTENSIN II, AVP
• HYPONATREMIA IS A MARKER FOR POOR CARDIAC OUTPUT AND NEUROHORMONAL ACTIVATION
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TREATING HYPONATREMIA IN ADHF
• WATER RESTRICTION< 2 L/DAY • MAXIMIZE ACEI OR ARB • VASOPRESSIN ANTAGONIST (TOLVAPTAN)
RESERVED FOR ADHF WITH HYPONATREMIA CAUSING SIGNIFICANT COGNITIVE SYMPTOMS
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VASODILATORS
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IV VASODILATORS USED IN ADHF
• NITROGLYCERIN
• NITROPRUSSIDE
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WHAT HAPPENED TO NESIRITDE?
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IV VASODILATORS: NESERITIDE AND THE ASCEND TRIAL
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HFSA GUIDELINES: TREATING ADHF PATIENTS WITH ACUTE PULMONARY EDEMA OR SEVERE HYPERTENSION
• IV NITROGLYCERIN OR NITROPRUSSIDE ARE RECOMMENDED FOR RAPID SYMPTOM RELIEF IN PATIENTS WITH ACUTE PULMONARY EDEMA OR SEVERE HYPERTENSION
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HF GUIDELINES: USING IV VASODILATORS IN ADHF
• IN THE ABSENCE OF SYMPTOMATIC HYPOTENSION, IV NITROGLYCERIN OR NITROPRUSSIDE MAY BE CONSIDERED AS AN ADDITION TO DIURETIC THERAPY FOR RAPID IMPROVEMENT OF CONGESTIVE SYMPTOMS IN PATIENTS ADMITTTED WITH ADHF
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HFSA GUIDELINES: OTHER USES OF IV VASODILATORS
• IV NITROGLYCERIN OR NITROPRUSSIDE MAY BE CONSIDERED IN PATIENTS WITH ADHF WHO HAVE PERSISTENT SEVERE HF DESPITE AGGRESSIVE TREATMENT WITH DIURETICS AND STANDARD ORAL THERAPIES
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IV NITROGLYCERIN • HEMODYNAMIC EFFECTS
– VENODILATOR; ARTERIAL VASODILATOR AT HIGH DOSES – DECREASES FILLING PRESSURE AT LOW DOSE; AT HIGH
DOSES, DECREASES SVR AND INCREASES CARDIAC OUTPUT
– INCREASED CORONARY BLOOD FLOW
• DOSE RANGE – INITIAL DOSE 20 mcg/min – INCREASE DOSE 20 mcg/min q 20 MINUTES – EFFECTIVE DOSE RANGE 40-400 mcg/min – KEEP SBP> 80, DECREASE SVR<1200, REDUCE PCWP < 16
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IV NITROGLYCERIN
• MAJOR LIMITATIONS – HEADACHE – HYPOTENSION (ESPECIALLY IF FILLNG PRESSURES
ARE LOW) – PROLONGED PROFOUND HYPOTENSION AND
BRADYCARDIA (RARE) – TACHYPHYLAXIS – 20% ARE NONRESPONDERS
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NITROPRUSSIDE
• HEMODYNAMIC EFFECTS – BALANCED VASODILATOR (BOTH VEINS AND
ARTERIOLES) – DECREASES FILLING PRESSURES, SVR, PVR, AND
INCREASES CI • DOSE RANGE
– INITIAL DOSE: 10 mcg/min – INCREASE DOSE 10-20 mcg/min q 10-20 MINUTES – EFFECTIVE DOSE RANGE: 30-350 mcg/min – KEEP SBP > 80 mm Hg, DECREASE SVR <1200, REDUCE
PCWP < 16
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NITROPRUSSIDE
• MAJOR LIMITATIONS – CYANIDE TOXICITY
• MANIFESTED BY NAUSEA AND “FEELING WEIRD” • MOST LIKELY TO DEVELOP WITH DOSE > 250 mcg/min x
>2 days • OCCURS IN SETTING OF LOW HEPATIC PERFUSION DUE
TO LOW CARDIAC OUTPUT
– ACCUMULATION OF THIOCYANATE • CAN OCCUR OVER DAYS DURING CHRONIC USE,
PARTICULARLY WITH IMPARIED RENAL FUNCTION
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INOTROPES: BEATING A DEAD HORSE
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RANDOMIZED CONTROLLED TRIALS SUPPORTING USE OF
INOTROPES IN ADHF:
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WHAT’S WRONG WITH INOTROPES IN ADHF?
• ARRHYTHMIAS (OPTIME-CHF) • HYPOTENSION (OPTIME CHF) • INCREASED TROPONIN RELEASE • INCREASE IN-HOSPITAL AND 6 MONTH
MORTALITY (ADHERE NATIONAL REGISTRY, ESCAPE TRIAL)
• DOES NOT SHORTEN HOSPITALIZATION (OPTIME-CHF)
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INOTROPES USED IN ADHF AND STARTING DOSES
• DOBUTAMINE:1-10 mcg/kg/min • MILRINONE: 0.01-0.75 mcg/kg/min • DOPAMINE: 1-4 mcg/kg/min • EPINEPHRINE AND NOREPINEPHRINE: 1
mcg/min
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HFSA GUIDELINES: WHEN TO USE INOTROPES
• IV INOTROPES (MILRINONE OR DOBUTAMINE) MAY BE CONSIDERED TO RELIEVE SYMPTOMS AND IMPROVE END-ORGAN DYSFUNCTION IN PATIENTS WITH ADVANCED HF WITH LOW OUTPUT SYNDROME, ESPECIALLY WITH SBP <90, SYMPTOMATIC HYPOTENSION WITH NORMAL FILLING PRESSURES, OR INTOLERANT OR UNRESPONSIVE TO VASODILATORS AND DIURETICS
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3 REQUIREMENTS FOR INOTROPE USE:
ADVANCED SYSTOLIC HEART FAILURE + LOW OUTPUT SYNDROME + HYPOTENSION OR VASODILATORS EITHER INEFFECTIVE OR
CONTRAINDICATED OR FLUID OVERLOADED AND UNRESPONSIVIE TO DIURETICS
OR MANIFEST DETERIORATING RENAL FUNCTION
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INOTROPES: WHAT IS ADVANCED SYTOLIC HF?
• LVEF IS REDUCED AND USUALLY DILATED
• INOTROPES ARE NOT APPROPRITE FOR HEART
FAILURE WITH PRESERVED EJECTION FRACTION
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INOTROPES: WHAT IS LOW OUTPUT SYNDROME IN ADHF?
DILATED LV WITH REDUCED LVEF + DIMINISHED PERIPHERAL PERFUSION OR END-
ORGAN DYSFUNCTION
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LOW OUTPUT SYNDROME IS USUALLY MANIFESTED BY ONE OR MORE OF
THE FOLLOWING:
• SBP < 90 MM Hg • SYMPTOMATIC HYPOTENSION WITH NORMAL
FILLING PRESSURES • LACK OF RESPONSE TO VASODILATORS • SBP TOO LOW FOR VASODILATORS • END ORGAN DYSFUNCTION, SUCH AS ELEVATED
BUN AND/OR CREATININE AND OLIGURIA, MENTAL STATUS CHANGES, OR ELEVATED LFTS
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HFSA GUIDELINES: WHEN TO USE INOTROPES IN ADHF
ADVANCED HF (LV DILATION AND REDUCED EF) + LOW OUTPUT SYNDROME + INTOLERANT TO VASODILATORS OR POOR RESPONSE TO DIURETICS OR WORSENING RENAL FUNCTION
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2 THINGS THAT MUST BE KNOWN BEFORE STARTING AN INOTROPE
• IV INOTROPES (MILRINONE OR DOBUTAMINE) ARE NOT RECOMMENDED UNLESS THE PA CATHETER READINGS OR CLEAR CLINICAL SIGNS DEMONSTRATE: – LEFT HEART FILLNG PRESSURES ARE ELEVATED
AND – CARDIAC INDEX IS SEVERELY IMPAIRED
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CASE #1
• 68 YEAR OLD MALE • ISCHEMIC CM WITH LVEF 25% ON MAXIMALLY
TOLERATED DOSE OF ALL APPROPIATE HF MEDS • HX: SEVERE DYSPNEA + ABDOMINAL SWELLING • EXAM: BP 95/56 HR PACED AT 70
– SEVERE JVD, MODERATE ASCITES, +3 EDEMA • LABS:
– CREAT RISE FROM BASELINE 1.3 TO 2.3 – BUN RISE FROM BASELINE 20 TO 52
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CASE #1
DO YOU STOP BETA BLOCKER AND START
INOTROPIC THERAPY?
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CASE #1: SOLUTION
• CONTINUE BETA BLOCKER
• INOTROPE SHOULD NOT BE INITATED • TREAT WITH IV DIURETICS AND VASODILATOR
THERAPY
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CASE #2
• 52 YEAR OLD FEMALE • DILATED NONISCHEMIC CM, LVEF 20% +
MODERATE MR • HX: PROGRESSIVE FATIGUE • EXAM:
– BP 86/60 (BASELINE); HR 95 – HEMODYNAMICS: PA 65/28, , RA 14, PCWP 25, CI 1.4,
SVR 1822 • LAB:
– CREAT STABLE FROM BASELINE AT 1.4
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CASE #2
SHOULD YOU START AN INOTROPE?
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CASE #2: SOLUTION
• NO CLINICAL SIGNS OF HYPOPERFUSION • SVR IS SIGNIFICANTLY ELEVATED AND SBP IS
>85
• INOTROPE IS NOT INDICATED • TREAT WITH IV DIURETIC AND NITROPRUSSIDE • DIURESIS + NITROPRUSIDE REDUCED MR,
DECREASED SVR, INCREASED CI, DECREASED FILLING PRESSURS, DECREASED PA PRESSURES
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CASE #3
• 70 YEAR OLD MALE WITH ADVANCED PROSTATE CA
• ISCHEMIC CM, LVEF 18% • HX: 2 EPISODES OF NEAR SYNCOPE.
HYPOTENSION PRECLUDES BETA BLOCKER; ON LISINOPRIL 2.5 mg DAILY
• EXAM: SOMNULENT DURING EXAM, BP 72/55, HR 70, NO JVD, CLEAR LUNGS, S3,COOL EXTREMITIES, TRACE EDEMA
• LABS: Cr 1.8
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CASE #3
SHOULD YOU START AN INOTROPE?
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CASE #3: SOLUTION
• INOTROPE SHOULD BE STARTED. • THIS IS CARDIOGENIC SHOCK. • BP TOO LOW FOR VASODILATOR • ADVANCED PROSTATE CA PRECLUDES VAD
AND TRANSPLANT • IT IS PERFECTLY ACCETPTABLE TO START
INOTROPE IN HOSPITAL AND SEND TO PALLIATIVE CARE OR HOSPICE WITH INOTROPE