From the Guidelines
Vasopressin is not recommended as a first-line treatment for cardiogenic shock, but it may be considered as an adjunctive therapy in specific cases, as evidenced by the lack of survival benefit in the VANISH trial 1. When considering the use of vasopressin in cardiogenic shock, it is essential to weigh the potential benefits against the risks. The study published in Intensive Care Medicine in 2018 1 highlights the importance of norepinephrine as the first-line vasoactive drug, with vasopressin being considered a second-line agent. The key points to consider when evaluating the use of vasopressin in cardiogenic shock include:
- The SOAP II trial reported a higher risk of mortality with dopamine compared to norepinephrine in cardiogenic shock 1
- Norepinephrine is associated with fewer arrhythmias and is likely the vasoactive drug of choice for most patients with cardiogenic shock 1
- The addition of low-dose vasopressin to norepinephrine did not improve survival in a large, double-blind trial of vasopressor-dependent shock 1
- Vasopressin may be beneficial in patients with less severe shock (norepinephrine < 15 µg/min), although this potential benefit was not excluded in the trial 1 In clinical practice, vasopressin should only be used as an adjunctive therapy in cardiogenic shock when patients have refractory hypotension despite adequate fluid resuscitation and initial vasopressor therapy, and under close monitoring of hemodynamic parameters.
From the FDA Drug Label
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action Vasopressin causes vasoconstriction by binding to V1 receptors on vascular smooth muscle coupled to the Gq/11-phospholipase C-phosphatidyl-inositol-triphosphate pathway, resulting in the release of intracellular calcium.
12. 2 Pharmacodynamics
At therapeutic doses exogenous vasopressin elicits a vasoconstrictive effect in most vascular beds including the splanchnic, renal and cutaneous circulation.
12. 3 Pharmacokinetics
Vasopressin plasma concentrations increase linearly with increasing infusion rates from 10 to 200 μU/kg/min.
14 CLINICAL STUDIES
Increases in systolic and mean blood pressure following administration of vasopressin were observed in 7 studies in septic shock and 8 in post-cardiotomy vasodilatory shock.
The FDA drug label does not directly answer the question of whether vasopressin is effective in treating cardiogenic shock. While it discusses the effects of vasopressin in vasodilatory shock and its mechanism of action, it does not provide direct evidence for its use in cardiogenic shock 2 2.
From the Research
Effectiveness of Vasopressin in Cardiogenic Shock
- The use of vasopressin in cardiogenic shock has been explored in several studies, with varying results 3, 4, 5, 6, 7.
- A study published in 2020 found that there was insufficient evidence to prove that any one vasopressor, including vasopressin, was superior to others in terms of mortality in cardiogenic shock patients 3.
- However, a more recent study from 2025 suggested that vasopressin may be associated with lower in-hospital mortality in patients with cardiogenic shock, particularly those requiring high-dose vasopressors 4.
- Another study from 2005 reviewed the use of vasopressin in patients with vasodilatory shock and found that it increased blood pressure and may improve renal function, but noted that side effects should not be underestimated 5.
- A 2019 review of inotropes and vasopressors use in cardiogenic shock found that norepinephrine may be preferred over epinephrine, and that dobutamine represents the first-line inotrope agent, while levosimendan can be used as a second-line agent 6.
- A randomized pilot study from 2011 compared norepinephrine-dobutamine to epinephrine in cardiogenic shock patients and found that both regimens increased cardiac index and oxygen-derived parameters, but epinephrine was associated with higher heart rates, arrhythmias, and lactic acidosis 7.
Clinical Use of Vasopressin
- The clinical use of vasopressin in cardiogenic shock is limited by the lack of solid evidence regarding its effectiveness in improving outcomes 3, 6.
- Vasopressin may be considered as an adjunctive, catecholamine-sparing vasopressor in cardiogenic shock, particularly in patients with right ventricular failure and pulmonary hypertension 3.
- However, its use should be limited to a temporary measure as a bridge to recovery, mechanical circulatory support, or heart transplantation, and should be carefully monitored due to potential side effects 3, 5.