Is epinephrine effective for heart failure with preserved ejection fraction (HFpEF) in the setting of cardiogenic shock?

Epinephrine is Not Recommended for Heart Failure with Preserved Ejection Fraction in Cardiogenic Shock

Epinephrine should not be used for heart failure with preserved ejection fraction (HFpEF) in cardiogenic shock and should be restricted to rescue therapy in cardiac arrest only. 1

Understanding HFpEF in Cardiogenic Shock

Cardiogenic shock with preserved ejection fraction represents a distinct clinical entity with different pathophysiology compared to the more common cardiogenic shock with reduced ejection fraction. While both conditions present with hypoperfusion, the underlying mechanisms and optimal treatments differ significantly.

Pathophysiology Considerations

• HFpEF in cardiogenic shock typically involves:
  • Diastolic dysfunction
  • Impaired ventricular filling
  • Preserved contractility
  • Often elevated systemic vascular resistance

Recommended Treatment Algorithm

First-Line Approach

1. Fluid challenge assessment

   • If clinically indicated, administer 250 mL fluid over 10-15 minutes 1
   • Only if no signs of overt fluid overload are present

2. Inotropic therapy (if SBP remains <90 mmHg after fluid optimization)

   • Dobutamine is the first-line inotropic agent 1
   • Levosimendan is an excellent alternative, especially in patients on beta-blockers 1, 2
     • Provides inotropic effect independent of β-adrenergic stimulation
     • Administer as continuous infusion (0.05–0.2 μg/kg/min for 24h)
     • Avoid bolus dose if SBP <100 mmHg 1

3. Vasopressor therapy (only if inotropes fail to restore adequate perfusion)

   • Norepinephrine is the recommended vasopressor if needed 1
   • Only indicated when inotropic agents and fluid challenge fail to restore SBP >90 mmHg with persistent signs of hypoperfusion 1

Why Epinephrine Should Be Avoided

Epinephrine is explicitly contraindicated in cardiogenic shock according to multiple guidelines:

• The ESC guidelines clearly state: "Epinephrine is not recommended as an inotrope or vasopressor in cardiogenic shock and should be restricted to use as rescue therapy in cardiac arrest" 1
• Epinephrine is associated with:
  • Increased incidence of refractory shock 2
  • Potential for excessive tachycardia
  • Increased myocardial oxygen consumption
  • Possible worsening of diastolic dysfunction (particularly problematic in HFpEF)
  • Observational studies suggest increased risk of death 2

Additional Management Considerations

• Mechanical circulatory support

  • Consider if pharmacological therapy fails to restore adequate perfusion 1
  • Not as first-line treatment

• Monitoring

  • Invasive arterial line monitoring is recommended 1
  • Continuous assessment of organ perfusion and hemodynamics

• Adjunctive therapies

  • Oxygen therapy and possibly non-invasive ventilation for hypoxemia 1
  • Transfer to tertiary care center with 24/7 cardiac catheterization capability 1

Important Caveats and Pitfalls

• Avoid excessive afterload increase: Since HFpEF patients often already have elevated systemic vascular resistance, vasopressors should be used with extreme caution and discontinued as soon as possible 1

• Recognize underlying causes: HFpEF cardiogenic shock may be precipitated by conditions like hypertensive crisis, tachyarrhythmias, or valvular disease that require specific management 3

• Beware of medication interactions: Recent research suggests norepinephrine use in cardiogenic shock may be associated with increased 30-day mortality, requiring careful monitoring 4

• Monitor tissue perfusion: Conventional hemodynamic targets may not guarantee adequate tissue perfusion, which is ultimately associated with outcomes 5

By following this evidence-based approach and avoiding epinephrine in favor of more appropriate agents like dobutamine or levosimendan (with norepinephrine only if necessary), clinicians can optimize management of HFpEF patients presenting with cardiogenic shock.