From the Guidelines
Norepinephrine is the recommended vasopressor for patients with hypotension and Acute Coronary Syndrome (ACS). The recommended starting dose is 0.1-0.5 mcg/kg/min administered through a central venous catheter, titrated to maintain a mean arterial pressure (MAP) of at least 65 mmHg 1. This is based on the most recent evidence from 2025, which suggests that norepinephrine is the preferred vasopressor due to its ability to increase blood pressure primarily through vasoconstriction with minimal direct effects on heart rate, thereby improving coronary perfusion without significantly increasing myocardial oxygen demand.
Some key points to consider when using norepinephrine in ACS patients include:
- Monitoring for tachycardia and adjusting the dose as needed
- Avoiding the use of phenylephrine and epinephrine as first-line agents due to their potential to worsen coronary ischemia
- Considering the addition of dobutamine (2.5-10 mcg/kg/min) for inotropic support if norepinephrine alone is insufficient
- Using vasopressin (0.01-0.04 units/min) as an adjunct to norepinephrine in refractory cases
- Continuously monitoring cardiac function, blood pressure, and tissue perfusion during vasopressor therapy
It's worth noting that the optimal target blood pressure in ACS patients is still debated, but the latest recommendations suggest aiming for a mean blood pressure of at least 65 mmHg 1. Additionally, the use of levosimendan, an inodilator, may be considered in certain cases, but further studies are needed to determine its efficacy and safety in ACS patients 1.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Norepinephrine Bitartrate Injection is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. An infusion of LEVOPHED should be given into a large vein (see PRECAUTIONS) Restoration of Blood Pressure in Acute Hypotensive States Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement CONTRAINDICATIONS LEVOPHED should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed
The best option for vasopressors in patients with hypotension and Acute Coronary Syndrome (ACS) is norepinephrine (IV), as it can be administered to maintain coronary artery perfusion until blood volume replacement therapy can be completed 2 2.
- Key considerations:
- Blood volume depletion should be corrected as fully as possible before any vasopressor is administered.
- Norepinephrine should be diluted in dextrose containing solutions prior to infusion.
- The infusion should be given into a large vein.
- Contraindications include hypotension from blood volume deficits, except as an emergency measure, and mesenteric or peripheral vascular thrombosis.
From the Research
Vasopressor Options for Hypotension and Acute Coronary Syndrome (ACS)
The choice of vasopressor for patients with hypotension and Acute Coronary Syndrome (ACS) is crucial for restoring adequate tissue perfusion and achieving a successful outcome.
- Norepinephrine (NE) is considered an appropriate first-line vasopressor for most patients with shock, including cardiogenic or septic shock, due to its reliable vasoconstrictor effects and lower risk of adverse events compared to other catecholamine vasopressors 3, 4.
- The use of norepinephrine has been compared to epinephrine in patients with cardiogenic shock after acute myocardial infarction, with results showing a higher incidence of refractory shock with epinephrine 5.
- Dopamine has been compared to norepinephrine as a first-line vasopressor in the treatment of cardiogenic shock, with no significant difference in in-hospital mortality between the two groups, but a reduced need for additional vasopressors with norepinephrine 6.
- Other vasoactive agents, such as vasopressin and angiotensin II, may be considered in specific situations, such as vasodilatory states or high renin levels, but more data are required to confirm their benefits 3, 4, 7.
Key Considerations
When choosing a vasopressor for patients with hypotension and ACS, it is essential to consider the individual patient's hemodynamic response and tailor therapy accordingly.
- The primary goal of vasopressor therapy is to restore adequate tissue perfusion and normalize cellular metabolism.
- The choice of vasopressor should take into account both arterial pressure and tissue perfusion.
- Timely initiation of optimal vasopressor therapy is crucial for achieving a successful outcome.
Available Evidence
The available evidence suggests that norepinephrine is a suitable first-line vasopressor for patients with hypotension and ACS, due to its reliable vasoconstrictor effects and lower risk of adverse events compared to other catecholamine vasopressors 3, 4, 5, 6.