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Untreated symptomatic severe aortic stenosis has a poor prognosis, with a 2-year survival of less than 50%, but this pales into insignificance when compared to the prognosis of those presenting with cardiogenic shock.1 As populations age the prevalence of aortic stenosis is increasing, and over the last 5 years, with the advent of transcatheter aortic valve implantation (TAVI), there has been a substantial increase in the proportion of patients who are amenable to definitive treatment.2 3 Thus there is a clear and increasing need to provide support for patients presenting with cardiogenic shock and aortic stenosis with a view to definitive treatment after stabilisation.
Inotropes are widely used in the treatment of cardiogenic shock, but there is no clear evidence that they provide prognostic benefit whether or not there is associated aortic stenosis. There is, however, evidence to support the role of intravenous nitroprusside in the management of critically ill patients with severe aortic stenosis.4 Twenty-five consecutive patients presenting with severe aortic stenosis, left ventricular impairment and decompensated heart failure were treated with intravenous nitroprusside until surgery, conversion to maintenance medical therapy or death. The applicability of this study to patients with cardiogenic shock is limited by the exclusion of patients with hypotension as defined by …