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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e965 CLINICAL STATEMENTS AND GUIDELINES Recommendation-Specific Supportive Text 1. The role for directed vasodilators in acute decompensated HF remains uncertain. Part of the rationale for their use is targeting pulmonary congestion, while trying to avoid some potential adverse consequences of loop diuretics. Patients with hypertension, coronary ischemia, or significant MR may be suitable candidates for the use of intravenous nitroglycerin. However, tachyphylaxis may develop within 24 hours, and up to 20% of those with HF may develop resistance to even high doses.3,4 Because of sodium nitroprusside’s potential for producing marked hypotension, invasive hemodynamic blood pressure monitoring (eg, an arterial line) is typically required, and nitroprusside is usually used in the intensive care setting; longer infusions of the drug have been associated, albeit rarely, with thiocyanate and cyanide toxicity, particularly in the setting of renal insufficiency and significant hepatic disease. Nitroprusside is potentially of value in severely congested patients with hypertension or severe MV regurgitation complicating LV dysfunction.5 Overall, there are no data that suggest that intravenous vasodilators improve outcomes in the patient hospitalized with HF; as such, use of intravenous vasodilators is limited to the relief of dyspnea in the hospitalized HF patient with intact or high blood pressure.6,7 9.4b. VTE Prophylaxis in Hospitalized Patients Recommendation for VTE Prophylaxis in Hospitalized Patients Referenced studies that support the recommendation are summarized in the Online Data Supplements. COR LOE Recommendation 1 B-R 1. In patients hospitalized with HF, prophylaxis for VTE is recommended to prevent venous thromboembolic disease.1–3 Synopsis HF has long been recognized as affording additional risk for venous thromboembolic disease. When patients are hospitalized for decompensated HF, or when patients with chronic stable HF are hospitalized for other reasons, they are at increased risk for venous thromboembolic disease. The risk may be associated with higher HF symptom burden.4 This risk may extend for up to 2 years after hospitalization but is greatest in the first 30 days.5,6 The use of anticoagulation with subcutaneous low-molecular-weight heparin, unfractionated heparin, fondaparinux, or approved DOAC are used for the prevention of clinically symptomatic deep vein thrombosis and pulmonary embolism.7,8 Recommendation-Specific Supporting Text 1. Trials using available antithrombotic drugs often were not limited to patients with HF but included patients with acute illnesses, severe respiratory diseases, or simply a broad spectrum of hospitalized medical patients.9–12 All included trials excluded patients perceived to have an elevated risk of bleeding complications or of toxicity from the specific agent tested (eg, enoxaparin in patients with compromised renal function). In some trials, aspirin was allowed but not controlled for as a confounding variable. Despite the increased risk for the development of VTE in the 30 days after hospitalization, the data for extending prophylaxis to the immediate post-hospital period have shown decreased development of VTE but were associated with increased bleeding events and overall do not appear to provide additional benefit.2,3,11 For patients admitted specifically for decompensated HF and with adequate renal function (creatinine clearance, >30 mL/min), randomized trials suggest that enoxaparin 40 mg subcutaneously once daily,1,13 unfractionated heparin 5000 units subcutaneously every 8 or 12 hours,14–17 or rivaroxaban 10 mg once daily11 will radiographically reduce demonstrable venous thrombosis. Effects on mortality or clinically significant pulmonary embolism rates are unclear. For obese patients, a higher dose of enoxaparin 60 mg once daily achieved target range of thromboprophylaxis without increased bleeding.12 9.5 Evaluation and Management of Cardiogenic Shock Recommendations for Evaluation and Management of Cardiogenic Shock Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 B-NR 1. In patients with cardiogenic shock, intravenous inotropic support should be used to maintain systemic perfusion and preserve end-organ performance.1–8 2a B-NR 2. In patients with cardiogenic shock, temporary MCS is reasonable when end-organ function cannot be maintained by pharmacologic means to support cardiac function.9–17 2a B-NR 3. In patients with cardiogenic shock, management by a multidisciplinary team experienced in shock is reasonable.17–22 2b B-NR 4. In patients presenting with cardiogenic shock, placement of a PA line may be considered to define hemodynamic subsets and appropriate management strategies.23–27 2b C-LD 5. For patients who are not rapidly responding to initial shock measures, triage to centers that can provide temporary MCS may be considered to optimize management.17–22 Synopsis Cardiogenic shock is a commonly encountered clinical challenge with a high mortality and is characterized by Downloaded from http://ahajournals.org by on October 7, 2026