Avoid exertion
ICD +/- pacer for ventricular dysrhythmias
Definitive treatment is myomectomy
Consider primary insult, which usually is preload issue (fluid depletion, bleed, etc.)
If decompensated presents as hypotensive CHF
Preserve preload
Careful hydration
Avoid high airway pressure if intubate
Limit tachycardia
Beta blockers
Avoid vasodilators (no nitrates)
Maintain sinus rhythm (i.e. cardiovert A. fib)
Increase afterload (hypotensive only)
Phenylephrine, max dose range depending on source
Start at 100 mcg/min (~1.5 mcg/kg/min for average adult)
Range usually 0.5 - 6.0 mcg/kg/min, with efficacy minimal beyond 6 mcg/kg/min)
Max phenylephrine infusion before other pressors
Fix acid-base disorder as acidosis may prevent pressor efficacy
Consider maxing vasopressin next
Pressor effects more preserved in hypoxia and acidosis
Preferred over pressors with beta agonism
Push dose pressor while waiting for IV drip:
Place 1mL of 10mg/mL phenylephrine in 100mL NS
Final concentration 100mcg/mL
Use 1-2mL q2-5min (100-200mcg) in 10mL syringe
Onset 1min; duration 20min
Preserve preload
Careful hydration
Avoid high airway pressure if intubate
Limit tachycardia
Beta blockers
Avoid vasodilators (no nitrates)
Maintain sinus rhythm (i.e. cardiovert A. fib)
Increase afterload (hypotensive only)
Phenylephrine, max dose range depending on source
Start at 100 mcg/min (~1.5 mcg/kg/min for average adult)
Range usually 0.5 - 6.0 mcg/kg/min, with efficacy minimal beyond 6 mcg/kg/min)
Max phenylephrine infusion before other pressors
Fix acid-base disorder as acidosis may prevent pressor efficacy
Consider maxing vasopressin next
Pressor effects more preserved in hypoxia and acidosis
Preferred over pressors with beta agonism
Push dose pressor while waiting for IV drip:
Place 1mL of 10mg/mL phenylephrine in 100mL NS
Final concentration 100mcg/mL
Use 1-2mL q2-5min (100-200mcg) in 10mL syringe
Onset 1min; duration 20min
Careful hydration
Avoid high airway pressure if intubate
Beta blockers
Phenylephrine, max dose range depending on source
Start at 100 mcg/min (~1.5 mcg/kg/min for average adult)
Range usually 0.5 - 6.0 mcg/kg/min, with efficacy minimal beyond 6 mcg/kg/min)
Max phenylephrine infusion before other pressors
Fix acid-base disorder as acidosis may prevent pressor efficacy
Consider maxing vasopressin next
Pressor effects more preserved in hypoxia and acidosis
Preferred over pressors with beta agonism
Push dose pressor while waiting for IV drip:
Place 1mL of 10mg/mL phenylephrine in 100mL NS
Final concentration 100mcg/mL
Use 1-2mL q2-5min (100-200mcg) in 10mL syringe
Onset 1min; duration 20min
Start at 100 mcg/min (~1.5 mcg/kg/min for average adult)
Range usually 0.5 - 6.0 mcg/kg/min, with efficacy minimal beyond 6 mcg/kg/min)
Max phenylephrine infusion before other pressors
Fix acid-base disorder as acidosis may prevent pressor efficacy
Consider maxing vasopressin next
Pressor effects more preserved in hypoxia and acidosis
Preferred over pressors with beta agonism
Pressor effects more preserved in hypoxia and acidosis
Preferred over pressors with beta agonism
Place 1mL of 10mg/mL phenylephrine in 100mL NS
Final concentration 100mcg/mL
Use 1-2mL q2-5min (100-200mcg) in 10mL syringe
Onset 1min; duration 20min
Per Amer Coll of Cardiology 2011 recommendations
Class I
beta-blockers for angina or dyspnea in adults in<unk> M regardless of obstructive physiology - use with caution in sinus brady or conduction abnormality
Titrate BB dose to symptoms, may increase BB dose to resting HR to 60 bpm
Verapamil PO titrated up to 480mg/d if patient unresponsive or cannot tolerate beta-blockers - caution in advanced HF, hypotension, sinus brady, high LVOT gradients
IV phenylephrine for acute hypotension unresponsive to fluids
Class IIa
Reasonable to add disopyramide with BB or verapamil if unresponsive to BB or CCB alone in obstructive<unk> M
Reasonable to add oral diuretics in nonobstructive<unk> M when symptoms persist despite BB or CCB
Class III (harm)
Avoid nifedipine and other dihydropyridine CCB
Avoid digoxin
Avoid disopyramide alone with out BB or CCB
Avoid positive inotropic vasopressors (dopamine, dobutamine, norepinephrine, epi)
beta-blockers for angina or dyspnea in adults in<unk> M regardless of obstructive physiology - use with caution in sinus brady or conduction abnormality
Titrate BB dose to symptoms, may increase BB dose to resting HR to 60 bpm
Verapamil PO titrated up to 480mg/d if patient unresponsive or cannot tolerate beta-blockers - caution in advanced HF, hypotension, sinus brady, high LVOT gradients
IV phenylephrine for acute hypotension unresponsive to fluids
Reasonable to add disopyramide with BB or verapamil if unresponsive to BB or CCB alone in obstructive<unk> M
Reasonable to add oral diuretics in nonobstructive<unk> M when symptoms persist despite BB or CCB
Avoid nifedipine and other dihydropyridine CCB
Avoid digoxin
Avoid disopyramide alone with out BB or CCB
Avoid positive inotropic vasopressors (dopamine, dobutamine, norepinephrine, epi)
Hypertrophic cardiomyopathy
Seizure
Restrictive cardiomyopathy
Breath-holding spell
Dilated cardiomyopathy
Hyperventilation syndrome
Mitral valve prolapse
Pregnancy 