Table 3.

Invasive Hemodynamic Guidance in Common Clinical Scenarios

Scenarios	BP	HR	RAP	PCWP	CO	SVR	Potential Action
Dyspnea and unclear volume status	-	-	-	-	-	-	Workup lung disease, non-cardiac dyspnea
	-	-	↑	↑↑	-	-	Diuresis
	-	-	↑↑	-/↓	-/↓	-/↑	Workup for PH, PE, Pericardial disease, RV MI
Unclear volume status, perfusion, vascular resistance; Worsening renal function during decongestion	-	-/↑	-/↓	-/↓	-/↓	-	Stop acute decongestion
	-/↑	-/↑	↑↑	↑↑	↓	↑↑	Diuresis + Vasodilator* Diurese to goal RAP (<8 mmHg), PCWP (<15 mmHg); vasodilate to reduce SVR (1000–1200 dynes/s/cm−5) while maintaining MAP (65–70 mmHg) - sacubitril/valsartan oral - hydralazine-isosorbide dinitrate oral - nitroprusside IV (0.25–5.0 mcg/kg/min**
	↓	↑	↑↑	↑↑	↓	-/↑	Inotrope* Inotropes to increase cardiac index (>2.0 L/min/m2) and MAP (>65 mmHg): - dobutamine (2.5–10 mcg/kg/min) - milrinone (0.125–0.500 mcg/kg/min)
Hypotension of unclear etiology	↓↓	↑	-/↓	-/↓	↓	↑↑	Hypovolemic shock likely. Treat with IV fluid, or blood, depending on cause.
	↓↓	↑	-	-	-/↑	↓↓	Distributive shock likely. Treat with IV fluid + vasopressor, workup etiology. Vasopressors to consider: - norepinephrine (0.01–2 mcg/kg/min) - vasopressin (0.04 U/min)
	↓↓	↑	↑↑	↑↑	↓↓	↓/↑	Cardiogenic shock likely. Inotrope/vasopressor ± temporary MCS, workup etiology. If hypotension severe, consider vasopressors: - epinephrine (0.01–0.1 mcg/kg/min) - norepinephrine (0.01–2 mcg/kg/min)

^*In general, vasodilator-based therapy is preferred if BP allows (e.g. MAP >65 mmHg) given the increases in myocardial O2 demand and proarrhythmia associated with inotropes

^**IV nitroprusside is monitored with invasive BP monitoring, then gradually transitioned to oral vasodilator therapy once desired hemodynamic effects have been achieved