Table 3.

Vasoactive management of cardiogenic shock profiles

Cause/presentation of CS	Vasoactive management considerations and rationale
‘Classic’ cold and wet	First line: norepinephrine for initial haemodynamic stabilisation (preferred as less arrhythmogenic). Following BP control the addition of inotropic agent should be considered.
Euvolaemic cold and dry	First line: norepinephrine, followed by addition of inotropic agent. LVEDP may be low and respond to judicious filling.
Mixed warm and wet	Complicated clinical picture. Consider PAC. Norepinephrine should be first-line agent with use of subsequent vasoactive agents guided by clinical and haemodynamic assessment.
Right ventricular failure	Maintain preload with careful fluid boluses. Norepinephrine to maintain RV coronary perfusion. Consider chronotrope if relatively bradycardic (HR <70 bpm). Vasopressin may increase SVR with equivocal effect on PVR. Inotropic support following initial stabilisation. Use of pulmonary vasodilators if PVR high.

Norepinephrine should generally be regarded as the first-line vasopressor.

BP, blood pressure; bpm, beats per minute; CS, cardiogenic shock; HR, heart rate; LVEDP, left ventricular end diastolic pressure; PAC, pulmonary artery catheter; PVR, pulmonary vascular resistance; RV, right ventricle; SVR, systemic vascular resistance.