What is the treatment for cardiogenic shock?

Treatment of Cardiogenic Shock

Immediately initiate norepinephrine as the first-line vasopressor and dobutamine as the first-line inotrope, while simultaneously pursuing urgent coronary angiography within 2 hours if acute myocardial infarction is the cause. 1

Initial Stabilization and Assessment

Establish invasive monitoring immediately with arterial line placement for accurate blood pressure measurement and frequent blood sampling. 1 Perform ECG and echocardiography without delay to confirm the diagnosis and identify the underlying cause. 1, 2

Classify shock severity using the SCAI 5-stage (A-E) classification system to guide treatment intensity and prognosis. 1 Consider early pulmonary artery catheter placement to identify the specific cardiogenic shock phenotype (LV-dominant, RV-dominant, biventricular, or normotensive hypoperfusion) and guide targeted therapy. 1

Fluid Management

Administer a fluid challenge first (saline or ringer lactate >200 mL over 15-30 minutes) if there are no signs of overt fluid overload. 1 This is the recommended first-line treatment before escalating to vasopressors or inotropes. Occult hypovolemia should always be suspected and corrected when present, particularly if requiring high vasopressor doses. 3

Pharmacological Support

Vasopressor Therapy

Norepinephrine is the preferred first-line vasopressor when mean arterial pressure requires pharmacologic support. 1, 4

• Start with 2-3 mL/minute (8-12 mcg/minute) of a 4 mcg/mL solution (4 mg in 1000 mL of 5% dextrose). 3
• Titrate to maintain systolic blood pressure 80-100 mmHg, or no higher than 40 mmHg below pre-existing systolic pressure in previously hypertensive patients. 3
• Average maintenance dose ranges from 0.5-1 mL/minute (2-4 mcg/minute), though occasionally much higher doses may be necessary. 3
• Administer through a central venous catheter to avoid extravasation. 3

Inotropic Therapy

Dobutamine (2-20 μg/kg/min) is the first-line inotropic agent to increase cardiac output. 1, 4

Milrinone may be considered as an alternative to dobutamine, particularly in patients on beta-blockers, with similar outcomes demonstrated in cardiogenic shock. 1 A 2021 randomized trial in the New England Journal of Medicine found no significant difference between milrinone and dobutamine for the composite outcome of death, cardiac arrest, mechanical support, myocardial infarction, stroke, or renal replacement therapy (49% vs 54%, P=0.47). 5

Phenotype-Specific Pharmacologic Strategies

For LV-dominant shock: Use dobutamine or milrinone to improve cardiac output. 1

For RV-dominant shock: Prioritize agents that increase systemic afterload without increasing pulmonary vascular resistance—specifically vasopressin or norepinephrine—to maintain RV perfusion pressure. 1

For biventricular shock: Use combination therapy tailored to invasive hemodynamic parameters. 1

For normotensive hypoperfusion: Consider vasodilators such as nitroprusside to improve cardiac output by reducing afterload. 1

Revascularization Strategy

In AMI-related cardiogenic shock, perform immediate coronary angiography within 2 hours with intent to revascularize. 1, 2 This is the most critical intervention for reducing mortality.

For SCAI stage C or D shock: Achieve initial stabilization with vasopressor therapy and mechanical ventilation before proceeding to revascularization. 1

Mechanical Circulatory Support

Consider short-term mechanical circulatory support in refractory cardiogenic shock based on patient age, comorbidities, and neurological function. 1, 4

Do not routinely use intra-aortic balloon pump (IABP) in cardiogenic shock—evidence from randomized studies does not support improved survival. 1, 4

For RV failure specifically: Consider RV-specific mechanical support devices (Impella RP, Protek Duo). 1

For progressive pulmonary hypertension with RV failure: Venoarterial extracorporeal membrane oxygenation may be preferred. 1

Special Etiologies

For valvular disease causing cardiogenic shock: Emergency cardiac surgery is the gold standard treatment. 1, 4

For arrhythmia-induced cardiogenic shock: Prioritize restoration of sinus rhythm. 1

For atrial fibrillation with cardiogenic shock: Amiodarone is the most efficient and safest agent for cardioversion. 1

System-Based Care

Transfer immediately to a tertiary care center with 24/7 cardiac catheterization capability and mechanical circulatory support availability. 1, 2, 4 Implement a multidisciplinary shock team approach for complex cases. 1, 4

For SCAI stage E (end-stage) cardiogenic shock: Consider palliative care consultation. 1

Critical Pitfalls to Avoid

Do not delay revascularization in AMI-related shock—the 2-hour window is critical. 1, 2

Avoid excessive inotrope use without addressing the underlying cause, as increased myocardial oxygen consumption can worsen ischemia and increase mortality. 6, 7

Do not abruptly withdraw vasopressor infusions—reduce gradually to avoid rebound hypotension. 3

Always suspect occult hypovolemia if requiring escalating vasopressor doses despite adequate cardiac output. 3