A 64-year-old with known ischaemic cardiomyopathy presents with pulmonary oedema, BP 82/50, lactate 4.5, creatinine doubled in 24 h. Walk me through your management.

Question

EF 25%, on bisoprolol, ramipril, furosemide. ECG: sinus tachycardia, old LBBB. Troponin mildly elevated, NT-proBNP 9,000. Cold peripheries, mottled knees, oliguric.

Accepted Answer

This patient is in **SCAI Stage C cardiogenic shock** until proven otherwise — hypoperfusion (lactate 4.5, AKI, mottling) on a background of severe LV dysfunction.

**ABCDE.** Airway patent; sit upright, **high-flow O2 / CPAP** for pulmonary oedema (NICE NG106). Two large-bore IV, arterial line, urinary catheter, continuous monitoring. ABG, lactate, troponin, NT-proBNP, U&E, LFTs, coagulation, group and save.

**Circulation — the key decision.** With SBP 82 and end-organ hypoperfusion, aggressive diuresis or nitrates alone will worsen shock. I would give a **cautious IV furosemide bolus** (e.g. 40–80 mg IV or his usual oral dose IV) and prepare for an infusion, but the priority is restoring perfusion: **noradrenaline** via central access targeting MAP ≥65, then add **dobutamine or milrinone** as an inotrope if cardiac output remains low (per ESC HF 2021).

**Stop nephrotoxins** — hold ACEi acutely, hold beta-blocker only if frank shock, hold metformin, review contrast plans.

**Identify the precipitant.** Bedside **TTE** to confirm severe LV impairment and exclude mechanical complications (acute MR, VSD, tamponade). 12-lead ECG and troponin trend — if ACS suspected, **urgent coronary angiography** (Class I, ESC ACS 2023).

**Escalate early.** This is a **shock-team conversation now** — my consultant cardiologist, ITU, and the tertiary centre for consideration of **mechanical circulatory support** (IABP, Impella, VA-ECMO) per the British Cardiovascular Society / NHS England shock pathway. INTERMACS profile 1–2.

**Communication** — SBAR to ITU and tertiary centre, candid conversation with the family about prognosis and ceilings of care, and clear documentation of escalation status. I would also discuss **ceiling of care** explicitly given EF 25% — this is a shared decision.

Acute decompensated heart failure with cardiogenic shock and worsening AKI

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