Vasoactive Agent Selection Strategies in the Management of Cardiogenic Shock

Cardiogenic shock is defined by inadequate blood flow to vital organs because of cardiac insufficiency and is often, but not always, manifest by hypotension. In an effort to mitigate end-organ hypoperfusion and modulate blood pressure, medical management with vasoactive agents is the initial strategy in virtually all patients with cardiogenic shock. This clinical primer describes the pharmacologic profiles of the currently used vasoactive agents and available comparative effectiveness data, reviews the pathophysiology of the most common phenotypic forms of cardiogenic shock, and provides a strategic framework for vasoactive agent selection and titration that integrates the pharmacology, pathophysiology, and hemodynamic derangements that define each shock phenotype. The practice-based approach to vasopressor selection strategy for the management of cardiogenic shock outlines the following steps: first, emergently protect the mean arterial pressure; then, define the hemodynamic phenotype of cardiogenic shock and identify (and address, in parallel) potential etiologies and contributors; next, set additional hemodynamic goals beyond mean arterial pressure; last, tailor pharmacotherapy through iterative assessments of perfusion and ongoing hemodynamic derangements.