'Cardiogenic shock' is a syndrome caused by a significant reduction in cardiac output resulting in hypotension with signs of impaired perfusion, including oliguria. Even with aggressive supportive therapy, mortality in patients with cardiogenic shock is very high. An echocardiogram should be obtained but this should not delay coronary angiography. Patients under the age of 75 should be referred for early coronary revascularisation (which is the only therapy shown to improve outcomes) and given maximum therapy while waiting. Patients over the age of 75 do not, on average, benefit from early revascularisation, but should be administered maximum medical therapy including adequate ventilation and intra-aortic balloon pump support. Management of hypotension may include inotropic support. Use:

Adrenaline should ideally be administered through a central venous catheter or at least a large antecubital vein. Alternative inotropic agents may be used after expert advice.

Once inotropes have been initiated, vasodilator drugs (eg glyceryl trinitrate [IV], sodium nitroprusside) may be employed if the blood pressure has risen sufficiently (systolic blood pressure at least 90 mm Hg). Use:

The possibility of cardiac rupture should be considered if there is sudden clinical deterioration. Immediate confirmation of cardiac tamponade by echocardiography, with urgent pericardiocentesis, can be life saving.