In cardiogenic shock with persistent hypotension despite inotropic support, the next step is to start which vasopressor?

• A. Epinephrine
• B. Dopamine
• C. Phenylephrine
• D. Norepinephrine

Answer: (D)

In cardiogenic shock with persistent hypotension despite inotropic support, the goal is to raise mean arterial pressure to ensure organ and coronary perfusion without overwhelming the heart. Norepinephrine fits best because it provides strong alpha-1–mediated vasoconstriction to raise blood pressure, while also offering some beta-1 activity to help support cardiac output. This combination improves perfusion pressure with less risk of causing excessive tachycardia or increased myocardial oxygen demand.

Other vasopressors have drawbacks in this setting. Epinephrine can dramatically raise heart rate and myocardial oxygen consumption, increasing the risk of ischemia and arrhythmias. Dopamine, at higher doses, can cause tachycardia and irregular rhythms and has a less favorable balance of effects in cardiogenic shock. Phenylephrine is a pure alpha-1 agonist that increases afterload without any inotropic support, which can further reduce cardiac output and worsen perfusion in a failing ventricle.

So, starting norepinephrine provides the best balance: raise perfusion pressure with supportive cardiac effects while minimizing adverse effects that could worsen cardiac performance.