Vasopressin in cardiogenic shock: pathophysiology, clinical evidence, and therapeutic perspectives

Vasopressin is a non-adrenergic vasopressor, commonly used in distributive shock, that may offer therapeutic benefits in selected phenotypes of cardiogenic shock. This review presents a comprehensive synthesis of its pharmacologic mechanisms, haemodynamic effects, clinical applications, and potential adverse outcomes in this complex setting. We delineate clinical scenarios in which vasopressin may be advantageous, critically appraise the current evidence, and support a physiology-guided, individualized approach to treatment. Patient profiles that may particularly benefit include advanced or mixed cardiogenic shock with low systemic vascular resistance, tachyarrhythmia-related shock, post-cardiac arrest shock, acute right ventricular failure, mitral stenosis, prosthetic mitral valve thrombosis, dynamic left ventricular outflow tract obstruction, Takotsubo syndrome, and severe aortic stenosis. In these settings, vasopressin's non-adrenergic mechanism of action may improve perfusion pressure while mitigating catecholamine-related adverse effects. We also outline clinical scenarios of cardiogenic shock in which vasopressin use may be detrimental and discuss its implications in patients receiving mechanical circulatory support. Finally, we highlight the need for prospective studies to optimize vasopressor selection in this high-risk and heterogeneous population.