Complete cardiogenic shock protocol, reworked from the original and reviewed on 22 October 2026. Free access. Includes recognition, treatment algorithm, monitoring, drug doses, advanced support and precautions.
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CARDIOGENIC SHOCK — COMPLETE PROTOCOL
Recognition • Stabilization • Cause-directed treatment
FREE ACCESS | Reviewed 22 October 2026
DEFINITION:
Organ hypoperfusion caused by primary cardiac dysfunction. Filling pressures are often elevated; right-sided and normotensive phenotypes also occur.
MAIN CAUSES:
• Acute coronary syndrome / myocardial infarction
• Acute decompensated heart failure
• Mechanical complications: ventricular septal defect, acute mitral regurgitation, free-wall rupture
• Myocarditis / cardiomyopathies
• Severe arrhythmias / acute valve disease
• Pulmonary embolism and tamponade: differential diagnoses of OBSTRUCTIVE shock
CLINICAL DIAGNOSIS:
• SBP <90 mmHg or need for support: common, not mandatory; do not wait 30 minutes
• Hypoperfusion: altered mentation, cold skin, urine <0.5 mL/kg/h, lactate >2 mmol/L
• Congestion: crackles, dyspnea, edema, raised jugular venous pressure
• CI <2.2 L/min/m² and PCWP >15 mmHg: classical left-sided criteria, not universal
• SCAI staging and serial reassessment
THERAPEUTIC GOALS:
• Restore tissue perfusion and organ function
• Optimize cardiac output and filling pressures
• Relieve congestion while maintaining perfusion
• Treat the underlying cause promptly
MONITORING:
• Continuous ECG, invasive BP when indicated, SpO₂
• Blood gas, serial lactate, creatinine, electrolytes
• Hourly urine output and echocardiography
• Central venous catheter: CVP and ScvO₂
• Pulmonary artery catheter when indicated: output, PAP, PCWP and SvO₂
• A central venous catheter alone does NOT measure PCWP
TREATMENT ALGORITHM — simultaneous actions
1 ASSESSMENT AND CONFIRMATION:
ABCDE; 12-lead ECG; blood count, troponin, kidney/liver function, electrolytes, blood gas and lactate; urgent echocardiography. Assess ischemia, mechanical complications and right/left ventricular dysfunction.
HYPOPERFUSION SIGNS: oliguria, altered mentation, cold skin, prolonged capillary refill, raised lactate. Integrate findings: no single sign confirms or excludes shock. Activate the Shock Team / cardiac ICU immediately.
2 OXYGENATION AND VENTILATION:
• Oxygen if SpO₂ <90% or PaO₂ <60 mmHg; avoid hyperoxia
• If oxygen is needed: usual target 94–98%; 88–92% if at risk of hypercapnia, guided by blood gas
• NIV for pulmonary edema with respiratory distress only if hemodynamically tolerated and airway protected
• Intubate for progressive failure, exhaustion or inability to protect the airway; prepare circulatory support
3 PRELOAD / AFTERLOAD:
• Assess volume status and congestion using examination, echo and dynamic response; do not rely on IVC alone
• Low preload without congestion: cautious 250 mL crystalloid challenge, reassess immediately
• Congestion: IV diuretic with supported perfusion; monitor kidney function and electrolytes
• Nitrates / nitroprusside: selected stabilized patients with adequate BP only; never in hypotensive shock
4 HEMODYNAMIC SUPPORT:
• Hypotension with hypoperfusion: titrated norepinephrine; initial MAP around 65 mmHg, individualized
• Persistent low output: consider dobutamine with adequate BP or vasopressor support
• Vasopressin: possible adjunct for refractory vasoplegia; not an automatic next step
• Lowest effective dose, shortest duration; monitor ischemia and arrhythmias
• Persistent hypoperfusion: reassess phenotype and consider early mechanical support
5 TREAT THE CAUSE:
• MI: urgent angiography and revascularization; initial PCI of the culprit lesion
• Mechanical complications: immediate cardiac surgery assessment
• Unstable arrhythmias: cardioversion / pacing when indicated
• Myocarditis and heart failure: specialist cause-directed treatment
• PE or tamponade: obstructive shock pathway and urgent causal treatment
ADVANCED SUPPORT
DEVICES:
• Microaxial flow pump: selected STEMI-shock patients, balance benefits and complications
• IABP: not routine; selected indications including mechanical complications
• VA-ECMO / other support: individualized expert-center selection, not indiscriminate use
• Durable ventricular assist / transplantation: appropriate candidates
EARLY REFERRAL:
Refractory shock, escalating support, rising lactate, worsening organ function or need for advanced support. Contact the referral center before circulatory collapse.
CONTINUOUS REASSESSMENT:
Hemodynamics, perfusion, lactate, urine output, blood gas, echo, drug response and SCAI stage. Gradually wean support after recovery.
INDIVIDUALIZED TARGETS:
• Initial MAP around 65 mmHg
• Urine output generally ≥0.5 mL/kg/h
• Falling lactate toward <2 mmol/L
• Improving mentation and peripheral perfusion
• ScvO₂ / SvO₂: trends and context, no universal threshold
• Filling pressures: phenotype-guided, no single PCWP target
IV DRUGS — ADULTS, TITRATE AND MONITOR:
Norepinephrine: 0.05–1 µg/kg/min, titrate to perfusion
Dobutamine: 2–10 µg/kg/min (ACC); up to 20 per specialist protocols
Vasopressin: 0.01–0.04 U/min, selective adjunct
Levosimendan: 0.05–0.2 µg/kg/min, specialist choice only; hypotension risk
Nitroglycerin: 10–200 µg/min, only after stabilization and SBP >110 mmHg
Nitroprusside: start 0.3 µg/kg/min, ICU monitoring only
Furosemide: 20–40 mg IV if diuretic-naïve; adjust for chronic therapy, renal function and response
PRECAUTIONS:
• Inotropes: arrhythmias, ischemia and hypotension
• Avoid indiscriminate fluid loading
• Nitrates: avoid in hypotension, preload dependence and recent PDE5 inhibitor use
• NIV/intubation may reduce venous return
• Doses are indicative: check product information, dilutions and local protocols
Reviewed references
- ESC Heart Failure 2026
- ACC Cardiogenic Shock 2025
- ACC/AHA Acute Coronary Syndromes 2025
- ESC Heart Failure 2021 — drug doses
Infographic reworked with AI assistance and documentary review. Educational support for professionals: consult official guidelines, product information and local protocols.