Management of Heart Failure with Severe Bradycardia and Hypotension

Immediate Stabilization

The American College of Cardiology and the American Heart Association recommend immediate intravenous inotropic or vasopressor support to restore systemic perfusion and preserve end-organ function in patients with cardiogenic shock, with a strength of evidence level of I (high) 1, 2
Assess for shock and hypoperfusion by checking for decreased urine output, altered mental status, cool extremities, and elevated jugular venous pressure, as recommended by the American College of Cardiology and the American Heart Association, with a strength of evidence level of I (high) 1, 2
Administer oxygen therapy to relieve hypoxemia-related symptoms, as recommended by the American College of Cardiology and the American Heart Association, with a strength of evidence level of I (high) 1, 2
The European Society of Cardiology recommends alternative vasopressor support with dobutamine 2.5-10 μg/kg/min if pulmonary congestion is dominant, with a strength of evidence level of IIa (moderate) 3

Perform invasive hemodynamic monitoring with pulmonary artery catheter to guide therapy, as recommended by the American College of Cardiology and the American Heart Association, with a strength of evidence level of I (high) 1, 2
Identify reversible causes of decompensation, including acute coronary syndrome, pulmonary embolism, infection/sepsis, renal failure, and medication or dietary noncompliance, as recommended by the American College of Cardiology and the American Heart Association, with a strength of evidence level of I (high) 1, 2

The European Heart Failure Association recommends reducing or stopping beta-blockers in patients with symptomatic severe hypotension, with a strength of evidence level of I (high) 4, 5, 6, 7
Reduce vasodilators (nitrates, hydralazine) if present, as recommended by the European Heart Failure Association, with a strength of evidence level of IIa (moderate) 4, 5, 6, 7

If elevated filling pressures with hypotension, provide inotropic support as primary intervention, as recommended by the American College of Cardiology and the American Heart Association, with a strength of evidence level of I (high) 1, 2
If low filling pressures (hypovolemia), provide cautious fluid challenge with crystalloid, as recommended by the European Society of Cardiology, with a strength of evidence level of IIa (moderate) 3

Continuously assess vital signs every 15 minutes during the acute phase, as recommended by the American College of Cardiology and the American Heart Association, with a strength of evidence level of I (high) 1, 2, 3
Monitor urine output hourly (target >0.5 mL/kg/hr), as recommended by the American College of Cardiology and the American Heart Association, with a strength of evidence level of I (high) 1

Once stabilized, gradually reduce inotropic support, as recommended by the American College of Cardiology and the American Heart Association, with a strength of evidence level of I (high) 1
Consider cardiac resynchronization therapy (CRT) if ventricular conduction delay is present and LVEF <40%, as recommended by the European Heart Failure Association, with a strength of evidence level of I (high) 4

When hemodynamics improve, restart GDMT in a specific order, starting with SGLT2 inhibitors, then mineralocorticoid receptor antagonists, followed by ACE inhibitors/ARBs/ARNI, and finally beta-blockers, as recommended by the European Heart Failure Association, with a strength of evidence level of IIa (moderate) 8