Cardiovascular Critical Care I
↓ CVP or PCWP
Preload
Afterload
Contractility
| • | 500 mL of |
|---|
crystalloid/
colloid
| • | Blood products |
|---|---|
| • | Passive leg |
raising
↑ PAP +/- ↑ HR
| • | Milrinone |
|---|---|
| • | Nitroglycerin |
| • | Nitroprusside |
| • | Inhaled |
vasodilators
↓ BP/↑ HR
| • | Phenylepherine |
|---|---|
| • | Vasopressin |
↓ BP
| • | Norepinephrine |
|---|---|
| • | Dopamine |
↑ BP +/- ↑ HR
| • | Nitroprusside |
|---|---|
| • | Nitroglycerin |
| • | Other IV |
antihypertensive
↓ CO/CI
Normotensive/Hypertensive
| • | Milrinone |
|---|---|
| • | Dobutamine |
↓ BP/unresponsive
| • | Norepinephrine |
|---|
↓ HR (symptomatic +/- ↓ BP)
| • | Epinephrine |
|---|---|
| • | Dobutamine |
| • | Isoproterenol |
| • | Dopamine |
| • | Loop +/- thiazide |
diuretic
| • | Other means of |
|---|
fluid removal
| • | Nitroglycerin (if |
|---|
adequate BP)
| • | Sodium |
|---|
nitroprusside (if
adequate BP)
↑ CVP
↑ PCWP
Adapted from: Blais, DM. PSAP- IV: Critical and urgent care. 2010
Patient Case
Questions 1–8 pertain to the following case.
J.M. is a 68-year-old man with a history of CAD including STEMI 6 months ago with placement of two drug-
eluting stents, type 2 diabetes, hypertension, dyslipidemia, gastroesophageal reflux disease, obstructive sleep
apnea, frequent epistaxis, ischemic cardiomyopathy (LVEF 30%–35%), and moderate to severe mitral regurgi-
tation. He is admitted to the cardiac intensive care unit for severe shortness of breath and altered mental status,
and he is currently on continuous positive airway pressure (CPAP). He has gained 13 kg during the past 2 weeks
(now weighs 121 kg) and has had decreased urine output, despite having had his diuretic dose increased. Home
medications include the following: aspirin 81 mg once daily, ticagrelor 90 mg every 12 hours, pantoprazole 40
mg once daily, atorvastatin 40 mg once daily, insulin glargine 10 units every night, metformin 500 mg every 12
hours, furosemide 40 mg twice daily, and potassium chloride 20 mEq twice daily. His wife states that he was
taking clopidogrel until 1 month ago, at which time he was given ticagrelor samples from his primary care phy-
sician because of cost concerns. A physical examination reveals rales throughout his lung fields. He is afebrile,
anxious, and alert.
Given J.M.’s comorbidities, some drugs or drug classes have proven mortality benefits. Which medications
could be added or modified to the patient’s home medication profile to further slow disease progression and
improve mortality?