Management of Hypotension in Myocardial Infarction

Initial Assessment and Reversible Causes

The European Society of Cardiology recommends identifying and correcting reversible causes of hypotension, including hypovolemia, vasovagal reactions, bradyarrhythmias, tachyarrhythmias, drug-induced hypotension, right ventricular infarction, and mechanical complications, before initiating vasopressor therapy 1, 2
Hypovolemia should be looked for by checking low jugular venous pressure, venoconstriction, and poor tissue perfusion, and responds to fluid infusion 3
Right ventricular infarction is characterized by high jugular venous pressure with poor tissue perfusion, bradycardia, and hypotension, and volume overload should be avoided as it worsens hemodynamics 2, 3

The American College of Cardiology recommends rapid IV volume loading as the first step in patients without clinical evidence of volume overload or pulmonary congestion 4, 5
Rhythm disturbances or conduction abnormalities causing hypotension must be corrected immediately, taking priority over vasopressor initiation 4, 5
Pulmonary artery catheter monitoring is indicated for progressive hypotension or suspected mechanical complications 4
Intra-arterial pressure monitoring is required for severe hypotension (systolic <80 mmHg) or cardiogenic shock 7, 8
The target pulmonary wedge pressure should be ≥15 mmHg with cardiac index >2 L/kg/min 3

Dobutamine is the preferred inotropic agent if hypotension persists after volume loading without pulmonary congestion, starting at 2.5 μg/kg/min and increasing gradually up to 10 μg/kg/min 2, 3, 5
Norepinephrine is the first-choice vasopressor for STEMI patients with hypotension, and should only be initiated after volume loading and rhythm correction if hypotension persists 4, 5

The European Society of Cardiology defines cardiogenic shock as persistent hypotension (SBP <90 mmHg) despite adequate filling status with signs of hypoperfusion, or requiring IV inotropes/mechanical support to maintain SBP >90 mmHg 1, 2
Immediate PCI is indicated for patients with cardiogenic shock if coronary anatomy is suitable, and is the definitive treatment that reduces mortality 1, 2

Beta-blockers or calcium channel antagonists should not be administered to patients in a low-output state due to pump failure, as this is a Class III recommendation (harm) 4, 5
Nitrates should be avoided if systolic blood pressure is <100 mmHg or >30 mmHg below baseline 4, 5