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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Cardiogenic shock

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Cardiogenic shock is an immediate resuscitation and transfer emergency: activate cardiology, critical care and—when structural disease is possible—cardiac surgery while ABCDE assessment, ECG, lactate and bedside echo proceed in parallel.

Synopsis

Recognise tissue hypoperfusion from cardiac failure, separate LV, RV and mechanical phenotypes and restore the cause and perfusion without delaying definitive intervention.

  • Shock is inadequate tissue perfusion, not a blood-pressure number alone: look for altered mentation, cool/mottled skin, oliguria, narrow pulse pressure, rising lactate and metabolic acidosis.
  • Common causes are acute MI, decompensated HFrEF, fulminant myocarditis, severe tachy/bradyarrhythmia, acute valve or post-MI mechanical complication and acute RV failure.
  • Bedside echo must rapidly distinguish LV failure, RV failure, tamponade, acute MR, VSD and major valve disease; a single estimated EF does not define the whole shock state.
  • In ACS shock, urgent culprit-vessel revascularisation is central; routine immediate non-culprit multivessel PCI is not the default.
  • Give fluid only when hypovolaemia or clear preload deficiency is present; repeated empirical boluses worsen pulmonary oedema and RV/LV congestion.
  • Use noradrenaline for hypotension and add an inotrope such as dobutamine when low output persists; doses are continuously titrated in critical care, not prescribed as fixed ward doses.
  • Vasoactive support is a bridge to cause control, recovery, temporary mechanical support or advanced therapy—not a definitive plan.
  • NICE 2026 restricts catheter-based LV microaxial flow pumps to designated PPCI centres with on-site intensive-care expertise and evidence-generation/governance arrangements.

Key red flags

Hypoperfusion

Confusion, agitation, cool mottled extremities, weak pulse, oliguria and rising lactate can precede severe hypotension.

LV-predominant shock

Pulmonary oedema, low output and poor LV function after MI or decompensated cardiomyopathy; acute MR or VSD may be the hidden driver.

RV-predominant shock

Raised JVP, hypotension and relatively clear lungs with RV dilation/dysfunction; consider RV infarction, PE or pulmonary-hypertension crisis.

Mechanical complication

New murmur, abrupt pulmonary oedema, biventricular failure, tamponade/PEA or sudden decline after MI demands surgical-level urgency.

Electrical cause

Sustained VT, very rapid AF, complete heart block or severe bradycardia can cause or compound shock; use RCUK peri-arrest pathways.

Investigation priorities

01
Continuous ECG and immediate 12-lead ECGFirst step

Detect STEMI/NSTE-ACS, arrhythmia or conduction disease.

Management branches

First-lineRecognise and mobilise

Suspected cardiogenic shock

  1. Start ABCDE, high-acuity monitoring, arterial blood gas/lactate, ECG, IV access and targeted oxygen/ventilation; call cardiology and critical care immediately.
  2. Obtain urgent bedside echo and look for ACS, arrhythmia, tamponade, acute MR/VSD, RV failure, PE, bleeding or sepsis.
  3. Use cautious fluid only for demonstrated underfilling; avoid routine boluses in congestion.
  4. Insert arterial monitoring early when vasoactive therapy is needed and track urine output and lactate clearance.

Key medicines

NoradrenalineThe cited ready-to-use SmPC, licensed for adults weighing over 50 kg, starts noradrenaline base at 0.05–0.15 micrograms/kg/min by central IV infusion pump, titrated in 0.05–0.1 micrograms/kg/min steps to perfusion/MAP; its maintenance range is 0.05–1.5 micrograms/kg/min.For this cited product use a central venous catheter and preferably arterial BP monitoring; do not transfer its concentration or limits to another preparation. Watch for arrhythmia, ischaemia and extravasation.
DobutamineUsually 2.5–10 micrograms/kg/min by continuous IV infusion, titrated to output and perfusion; higher doses are exceptional.Tachyarrhythmia, increased myocardial oxygen demand, ischaemia and hypotension; ICU/cardiology supervision only.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG187: Acute heart failureUK inotrope/vasopressor use for potentially reversible shock.
  • NICE NG185: Acute coronary syndromesACS reperfusion pathway.
  • ESC 2023 Guidelines for acute coronary syndromesCulprit PCI and cardiogenic-shock context.
  • NICE HTG775: Catheter-based LV microaxial flow pump for cardiogenic shockMarch 2026 centre and evidence-generation restrictions.
  • Noradrenaline 0.08 mg/mL SmPCLicensed weight-based infusion dosing.
  • Dobutamine 5 mg/mL SmPCLicensed dose range.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom