LV failure

• Diurese to achieve PCWP ~14 → ↓ pulmonary edema, ↓ myocardial O2 demand
• ↓ Afterload → ↑ stroke volume & CO, ↓ myocardial O2 demand. Can use IV NTG or nitroprusside (although risk of coronary steal) → short-acting ACEI.
• Inotropes if HF despite diuresis & ↓ afterload; use dopamine, dobutamine, or milrinone
• Cardiogenic shock (~7%) = MAP <60 mmHg, CI <2.2 L/min/m2, PCWP >18 mmHg. If not done already, coronary revasc (NEJM 1999;341:625) Support w/ inotropes or mechanical circulatory support to keep CI >2 Intraaortic balloon pump (IABP) counterpulsation offers ~0.5 L/min CO and ↑ coronary perfusion, but no survival benefit if early revasc (NEJM 2012;367:1287) Axial flow pumps (eg, Impella) offer up to 3–5 L/min CO, but no data that improves clinical outcomes (JACC 2017;69:278)