Pharmacological treatment of cardiogenic shock

Cardiogenic shock remains associated with high mortality despite advances in revascularization and mechanical circulatory support. Pharmacological management, primarily based on vasopressors and inotropes is essential to restore perfusion but remains poorly standardized. This review summarizes recent advances and evolving concepts in the pharmacological treatment of cardiogenic shock, including the transition toward early heart failure therapies.

Norepinephrine is consistently recommended as the first-line vasopressor due to its favorable hemodynamic profile and lower arrhythmic risk compared with dopamine. Increasing evidence suggests that epinephrine may be associated with adverse metabolic and clinical effects, including higher rates of refractory shock. Dobutamine remains the most commonly used inotrope, although no clear superiority has been demonstrated over alternative agents such as milrinone or levosimendan. Strategies aimed at reducing catecholamine exposure, including the use of nonadrenergic agents such as vasopressin and early mechanical circulatory support, are gaining interest. In parallel, recent studies suggest that early initiation of guideline-directed heart failure therapies during stabilization may improve long-term outcomes.

Pharmacological management of cardiogenic shock should balance restoration of perfusion and minimization of drug-related toxicity. A continuum approach integrating acute hemodynamic support with early disease-modifying therapy may represent a key strategy to improve outcomes in this high-risk population.