What vasopressors are appropriate for a 68‑year‑old woman (59 kg) with a left ventricular ejection fraction of about 47 % undergoing sedation for coronary angiography?

Vasopressor Selection for Coronary Angiography in a Patient with EF 47%

For this 68-year-old woman with mildly reduced left ventricular ejection fraction (47%) undergoing coronary angiography, norepinephrine is the first-line vasopressor if hypotension develops, starting at 0.02–0.05 µg/kg/min and titrating to maintain MAP ≥ 65 mmHg. 1

Pre-Procedural Preparation

Before initiating any vasopressor during the procedure, ensure the following safeguards are in place:

• Establish a free-flowing intravenous line before sedation begins 2
• Have high-flow oxygen, suction, airway management equipment, defibrillator, resuscitation drugs, and reversal agents immediately available 2
• Monitor level of consciousness, respiratory rate, blood pressure, cardiac rhythm, and oxygen saturation continuously 2
• Assign dedicated personnel to observe sedation level and effects throughout the procedure 2

First-Line Vasopressor Strategy

Norepinephrine remains the mandatory first choice even in patients with reduced ejection fraction:

• Start at 0.02–0.05 µg/kg/min (approximately 1.2–3 µg/min for a 59 kg patient) and titrate upward to achieve MAP ≥ 65 mmHg 1, 3
• Administer through the most secure IV access available; central access is ideal but peripheral administration is acceptable while establishing central access 1
• Norepinephrine increases MAP through alpha-adrenergic vasoconstriction with modest beta-1 cardiac stimulation, maintaining cardiac output while raising systemic vascular resistance 1, 4
• In sepsis specifically, norepinephrine improves renal blood flow despite typically causing renal vasoconstriction in other contexts 5

Special Considerations for Reduced Ejection Fraction

The 47% ejection fraction does not contraindicate norepinephrine but requires heightened vigilance:

• Norepinephrine may increase myocardial oxygen demand, but this concern does not contraindicate its use in patients with ischemic heart disease 5
• If hypotension persists despite adequate MAP and norepinephrine, consider adding dobutamine 2.5–10 µg/kg/min only when echocardiography or hemodynamic monitoring demonstrates low cardiac output with adequate preload 1, 3
• Continue chronic beta-blockers unless acute hemodynamic decompensation or cardiogenic shock develops 5

Second-Line Options if Norepinephrine Alone is Insufficient

If MAP remains < 65 mmHg despite norepinephrine at 0.1–0.2 µg/kg/min:

• Add vasopressin at a fixed dose of 0.03 units/min (never as monotherapy, never titrate beyond 0.03–0.04 units/min) 1, 5
• Alternatively, add epinephrine 0.05–2 µg/kg/min if additional vasopressor effect is needed, particularly when myocardial dysfunction is present due to its inotropic properties 1, 3

Agents to Avoid in This Clinical Context

Dopamine should be avoided entirely:

• Dopamine causes significantly more arrhythmias (53% increased risk of supraventricular arrhythmias, 65% increased risk of ventricular arrhythmias) and higher mortality compared to norepinephrine 1, 5
• Dopamine provides no renal protective benefit and should never be used for that indication 1, 5
• Reserve dopamine only for highly selected patients with absolute bradycardia and low arrhythmia risk—not applicable during coronary angiography 1, 6

Phenylephrine has extremely limited indications:

• Use phenylephrine only if norepinephrine causes severe arrhythmias or when cardiac output is documented to be high with persistent hypotension 1, 5
• Phenylephrine may raise blood pressure numbers while actually worsening tissue perfusion through excessive vasoconstriction 1

Critical Monitoring During the Procedure

• Maintain continuous arterial blood pressure monitoring if vasopressors are initiated 1, 5
• Monitor for signs of excessive vasoconstriction: digital ischemia, decreased urine output, rising lactate, or worsening organ dysfunction despite adequate MAP 1
• Assess tissue perfusion using lactate levels, urine output, mental status, and capillary refill—not MAP alone 1, 5

Common Pitfalls to Avoid

• Do not delay norepinephrine while pursuing aggressive fluid resuscitation if severe hypotension develops during the procedure 5
• Do not use vasopressors as a substitute for adequate volume replacement if hypovolemia is the primary issue 1
• Do not combine dopamine with epinephrine due to additive adverse effects 5
• Monitor for extravasation if norepinephrine is given peripherally and infiltrate 5–10 mg phentolamine diluted in 10–15 mL saline immediately if it occurs 5