The like- lihood of developing cardiogenic shock was increased in certain subgroups, including patients with age >70 years, Table 12. Selected Routine Medical Therapies Therapy Indications Dose/Administration Avoid/Caution Beta-Receptor Antagonists Oral: All patients without contraindication IV: Patients with refractory hypertension or ongoing ischemia without contraindication Individualize: Metoprolol tartrate 25 to 50 mg every 6 to 12 h orally, then transition over next 2 to 3 d to twice-daily dosing of metoprolol tartrate or to daily metoprolol succinate; titrate to daily dose of 200 mg as tolerated Carvedilol 6.25 mg twice daily, titrate to 25 mg twice daily as tolerated Metoprolol tartrate IV 5 mg every 5 min as tolerated up to 3 doses; titrate to heart rate and BP Signs of HF Low output state Increased risk of cardiogenic shock Prolonged first-degree or high-grade AV block Reactive airways disease ACE Inhibitors For patients with anterior infarction, post-MI LV systolic dysfunction (EF 0.40) or HF May be given routinely to all patients without contraindication Individualize: Lisinopril 2.5 to 5 mg/d to start; titrate to 10 mg/d or higher as tolerated Captopril 6.25 to 12.5 mg 3 times/d to start; titrate to 25 to 50 mg 3 times/d as tolerated Ramipril 2.5 mg twice daily to start; titrate to 5 mg twice daily as tolerated Trandolapril test dose 0.5 mg; titrate up to 4 mg daily as tolerated Hypotension Renal failure Hyperkalemia ARB For patients intolerant of ACE inhibitors Valsartan 20 mg twice daily to start; titrate to 160 mg twice daily as tolerated Hypotension Renal failure Hyperkalemia Statins All patients without contraindications High-dose atorvastatin 80 mg daily Caution with drugs metabolized via CYP3A4, fibrates Monitor for myopathy, hepatic toxicity Combine with diet and lifestyle therapies Adjust dose as dictated by targets for LDL cholesterol and non HDL cholesterol reduction Nitroglycerin Ongoing chest pain Hypertension and HF 0.4 mg sublingual every 5 min up to 3 doses as BP allows IV dosing to begin at 10 mcg/min; titrate to desired BP effect Avoid in suspected RV infarction Avoid with SBP <90 mmHg or if SBP >30 mmHg below baseline Avoid if recent (24 to 48 h) use of Oxygen Clinically significant hypoxemia (oxygen saturation <90%) HF Dyspnea 2 to 4 L/min via nasal cannula Increase rate or change to face mask as needed Caution with chronic obstructive pulmonary disease and CO2 retention Morphine Pain Anxiety Pulmonary edema 4 to 8 mg IV initially, with lower doses in elderly 2 to 8 mg IV every 5 to 15 min if needed Lethargic or moribund patient Hypotension Bradycardia Known hypersensitivity ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; AV, atrioventricular; BP, blood pressure; CO2 , carbon dioxide; EF, ejection fraction; HDL, high-density lipoprotein; HF, heart failure; IV, intravenous; LDL, low-density lipoprotein; LV, left ventricular; MI, myocardial infarction; RV, right ventricular; and SBP, systolic blood pressure. 