---
title: Cardiogenic shock
description: What cardiogenic shock is — a state in which the heart suddenly pumps out too little blood and the organs run short of oxygen — why it happens, how to recognise it, how it is treated in hospital and why an ambulance should be called straight away if its signs appear.
type: disease
aliases:
  - shock after a heart attack
sources:
  - tier: guideline
    org: minzdrav-rf
    title: Острый инфаркт миокарда с подъемом сегмента ST электрокардиограммы
    year: 2024
    doi: 10.15829/1560-4071-2025-6306
    url: https://cr.minzdrav.gov.ru/view-cr/157_5
  - tier: guideline
    org: minzdrav-rf
    title: Хроническая сердечная недостаточность
    year: 2024
    doi: 10.15829/1560-4071-2024-6162
    url: https://cr.minzdrav.gov.ru/view-cr/156_2
  - tier: guideline
    org: esc
    title: 2026 ESC Guidelines for the management of heart failure
    year: 2026
    doi: 10.1093/eurheartj/ehag100
    url: https://doi.org/10.1093/eurheartj/ehag100
  - tier: guideline
    org: esc
    title: 2023 ESC Guidelines for the management of acute coronary syndromes
    year: 2023
    doi: 10.1093/eurheartj/ehad191
    url: https://doi.org/10.1093/eurheartj/ehad191
  - tier: reference
    org: msd-manuals
    title: Shock
    year: 2026
    url: https://www.msdmanuals.com/professional/critical-care-medicine/shock-and-fluid-resuscitation/shock
  - tier: reference
    org: msd-manuals
    title: Complications of Acute Coronary Syndromes
    year: 2026
    url: https://www.msdmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/complications-of-acute-coronary-syndromes
  - tier: reference
    org: msd-manuals
    title: Shock (Consumer Version)
    year: 2026
    url: https://www.msdmanuals.com/home/heart-and-blood-vessel-disorders/low-blood-pressure-and-shock/shock
  - tier: reference
    org: statpearls
    title: Cardiogenic Shock
    year: 2023
    url: https://pubmed.ncbi.nlm.nih.gov/29489148/
sources_checked: 2026-10-14
review: null
---

Cardiogenic shock is a life-threatening state in which the heart's output of blood falls sharply and the organs and tissues receive too little blood and oxygen.<Cite n={[1, 5]} /> It is the most severe form of acute heart failure in ST-elevation myocardial infarction.<Cite n={1} /> Medical shock has nothing to do with the "shock" people feel after a sudden emotional upset.<Cite n={7} /> The most common cause of cardiogenic shock is an acute [heart attack (myocardial infarction)](../myocardial-infarction/), but other disorders of the heart muscle, valves or conduction system of the heart can also cause it.<Cite n={8} /> Untreated, shock is usually fatal.<Cite n={[5, 7]} />

<Diagram name="cardiogenic-shock">
  <p slot="normal">
    Normally the heart pumps out enough blood with each beat, and the brain, kidneys, skin and
    other organs get enough oxygen from it.<Cite n={7} />
  </p>
  <p slot="disease">
    In cardiogenic shock the heart pumps out too little blood — most often because the part of the
    left ventricle damaged by the infarction does not contract normally.<Cite n={[1, 5, 8]} /> The
    organs run short of blood: the skin becomes cold, clammy and mottled, little urine is passed
    and consciousness is impaired.<Cite n={[1, 2]} /> The pulse is usually weak and
    rapid.<Cite n={7} /> Congestion in the lungs develops quickly.<Cite n={6} />
  </p>
</Diagram>

## Why it happens

<Patient>

Most often cardiogenic shock is a complication of a heart attack: the damaged part of the muscle cannot contract normally, and the heart pumps out less blood.<Cite n={[5, 8]} /> Other causes are a sudden failure of a heart valve (especially an artificial one), heart rhythm problems in which the pulse is too fast or too slow, inflammation of the heart muscle ([myocarditis](../myocarditis/)) or of the valves ([infective endocarditis](../infective-endocarditis/)), and a rupture of the heart wall.<Cite n={[5, 7]} /> A sharp worsening of [heart failure](../heart-failure/) can also end in shock.<Cite n={2} />

At first the body tries to help itself: the blood vessels narrow, the pulse speeds up, and blood is sent first of all to the heart and the brain.<Cite n={5} /> But the heart itself also gets too little blood and contracts even more weakly, so the condition keeps getting worse.<Cite n={5} />

Obstructive shock can look similar, but it is not cardiogenic shock: here something mechanically stops the heart from filling with blood or pumping it out, for example in [cardiac tamponade](../cardiac-tamponade/) or [pulmonary embolism](../pulmonary-embolism/).<Cite n={5} />

</Patient>

<Student>

Shock is tissue hypoperfusion caused by acute circulatory failure; by mechanism it is classified as hypovolaemic, cardiogenic, obstructive or distributive.<Cite n={5} /> About 5–10% of patients with acute myocardial infarction develop cardiogenic shock.<Cite n={6} /> The Russian Ministry of Health guideline describes three pathogenetic variants: true cardiogenic shock (with reduced LV contractility), shock due to relative and absolute hypovolaemia (with the closely related reflex shock, a reaction to an attack of pain) and an arrhythmic variant with severe tachy- and bradyarrhythmias.<Cite n={1} /> In the SHOCK registry the causes of cardiogenic shock in myocardial infarction were reduced LV contractility in 79%, acute mitral regurgitation in 7%, ventricular septal rupture in 4% and isolated right ventricular failure in 2%.<Cite n={1} />

When oxygen delivery is inadequate, cells shift to anaerobic metabolism and lactate rises; if shock persists, cell damage becomes irreversible.<Cite n={5} /> Reduced coronary perfusion and inflammatory mediators may depress contractility and arrhythmias may occur; cardiac output falls further and a progressive deterioration follows.<Cite n={5} /> Renal hypoperfusion leads to acute tubular necrosis with oliguria and a rising creatinine, and hepatic hypoperfusion to hepatocellular necrosis with raised transaminases and bilirubin; the progressive dysfunction of two or more organs is called multiple organ dysfunction syndrome.<Cite n={5} />

MSD classifies obstructive shock separately: tension pneumothorax and tamponade interfere with ventricular filling, pulmonary embolism with ventricular emptying.<Cite n={5} />

</Student>

## Symptoms

<Patient>

Shock may begin with sluggishness, sleepiness and confusion.<Cite n={7} /> The skin becomes cold and sweaty, often bluish, pale or ashen.<Cite n={7} /> The pulse is weak and rapid, unless a slow heartbeat is causing the shock.<Cite n={7} /> Usually the person cannot sit up without feeling light-headed or fainting.<Cite n={7} /> Breathing is rapid, and less and less urine is passed until it stops altogether.<Cite n={7} /> Congestion in the lungs develops quickly, and breathlessness may appear.<Cite n={[5, 6]} /> There may also be symptoms of the cause of the shock, such as chest pain.<Cite n={5} />

Blood pressure in shock is usually low, but at the very beginning it may still be normal.<Cite n={[5, 7]} /> So a normal reading on a blood pressure monitor does not rule out shock.<Cite n={[5, 7]} />

</Patient>

<Student>

The Russian Ministry of Health guideline names persistent hypotension (systolic BP ≤ 90 mm Hg), refractory to fluid therapy and accompanied by signs of acute multiple organ failure, as the main clinical sign of cardiogenic shock.<Cite n={1} /> Hypotension is common in shock but not required, especially early on, and not every patient with hypotension is in shock.<Cite n={5} /> The ESC lists as signs of hypoperfusion cold, sweaty extremities, pale skin, dizziness, mental confusion, oliguria, narrow pulse pressure and raised serum lactate, creatinine and aminotransferases.<Cite n={3} />

In myocardial infarction, cardiogenic shock corresponds to Killip class IV acute heart failure.<Cite n={1} /> In the Russian Ministry of Health classification of acute decompensated chronic heart failure, class 4 (C) is "cold" and "wet": there is both peripheral hypoperfusion and moist rales in the lungs.<Cite n={2} /> Right ventricular infarction usually accompanies inferior LV infarction; its first sign may be hypotension in a patient who had been stable.<Cite n={6} />

By clinical severity and response to treatment, the Russian Ministry of Health guideline distinguishes pre-shock (no signs of shock yet, but a risk of it — acute MI, acute heart failure or decompensated chronic heart failure), established cardiogenic shock and refractory shock, which does not improve with treatment.<Cite n={1} /> The ESC and the Russian Ministry of Health guideline also describe the SCAI stages: A — at risk; B — beginning shock with haemodynamic instability without hypoperfusion; C — classic shock with hypoperfusion requiring inotropes, vasopressors or mechanical support; D — deteriorating, with failure to respond to initial interventions; E — extremis, refractory shock or cardiac arrest with ongoing resuscitation.<Cite n={[1, 3]} />

</Student>

## How it is diagnosed

<Patient>

Shock is recognised first of all on examination: the doctor checks consciousness, skin, pulse, blood pressure, breathing and how much urine is passed.<Cite n={[5, 7]} /> An [ECG](../../diagnostic/ecg/) is recorded as soon as possible to look for rhythm problems or signs of a heart attack, and an [ultrasound scan of the heart (echocardiography)](../../diagnostic/echocardiography/) is done urgently: it shows how the heart contracts and helps find the cause of the shock.<Cite n={[2, 4]} /> A blood test for lactate shows whether the organs are getting enough oxygen, and creatinine whether the kidneys are affected.<Cite n={7} /> If the cause is a heart attack, coronary angiography — an examination of the heart's arteries — is done straight away.<Cite n={4} />

</Patient>

<Student>

In suspected ACS presenting with cardiogenic shock or suspected mechanical complications, the ESC recommends emergency transthoracic echocardiography.<Cite n={4} /> In acute decompensated heart failure with shock, the Russian Ministry of Health guideline recommends echocardiography immediately, and a 12-lead ECG as soon as possible to detect rhythm and conduction disturbances and exclude ACS.<Cite n={2} /> Laboratory work-up includes lactate, urea and creatinine, liver tests, a full blood count, coagulation tests and arterial blood gases; no single finding is diagnostic on its own, and the trend matters.<Cite n={5} />

Chest pain may suggest MI, aortic dissection or pulmonary embolism, and a systolic murmur in acute MI may indicate ventricular septal rupture or mitral regurgitation.<Cite n={5} /> The Russian Ministry of Health guideline suggests considering invasive monitoring of central haemodynamics and pulmonary artery catheterisation to guide treatment and clarify the cause of shock.<Cite n={1} />

</Student>

## How it is treated

<Patient>

Cardiogenic shock is treated in hospital, usually in an intensive care unit.<Cite n={[5, 7]} /> The main thing is to treat the cause of the shock.<Cite n={7} /> If the cause is a heart attack, blood flow in the blocked heart artery is restored as quickly as possible: usually the artery is widened through a catheter and a stent is placed, and if that is not possible, urgent coronary bypass surgery is done.<Cite n={[1, 4, 5]} /> If the cause is a damaged valve or a rupture of the heart wall, surgery may be needed.<Cite n={[5, 7]} />

To support the circulation, medicines that strengthen the heart's contractions or narrow the blood vessels and raise blood pressure are given into a vein.<Cite n={[3, 7]} /> If needed, oxygen is given or the person is put on a breathing machine (mechanical ventilation).<Cite n={5} /> Some patients are temporarily connected to mechanical circulatory support devices that help the heart pump blood; the ESC recommends that a team of specialists chooses the device.<Cite n={[3, 6]} /> Doctors decide which treatment is needed.

</Patient>

<Student>

Reperfusion and revascularisation are the basis of treating cardiogenic shock in STEMI: the Russian Ministry of Health guideline recommends PCI of the infarct-related artery regardless of the time since symptom onset, and emergency coronary artery bypass grafting if PCI is not possible or unsuccessful.<Cite n={1} /> The ESC 2023 guideline recommends immediate coronary angiography and PCI of the infarct-related artery in cardiogenic shock complicating ACS, and emergency CABG if PCI of the infarct-related artery is not feasible or unsuccessful.<Cite n={4} /> During the index procedure only the infarct-related artery is treated; the ESC suggests considering staged PCI of the other arteries.<Cite n={[1, 4]} /> If primary PCI is not available within 120 minutes of the STEMI diagnosis and mechanical complications have been ruled out, the Russian Ministry of Health guideline recommends, and the ESC suggests considering, fibrinolysis.<Cite n={[1, 4]} /> In cases of haemodynamic instability, mechanical complications of ACS are repaired as an emergency, surgically or by catheter, based on a Heart Team discussion.<Cite n={4} />

The ESC 2026 guideline states that inotropic agents may be considered at a systolic BP < 90 mm Hg with evidence of hypoperfusion not responding to standard treatment, including a fluid challenge, and vasopressors to increase blood pressure and vital organ perfusion (IIb C).<Cite n={3} /> At a systolic BP below 90 mm Hg without signs of hypoperfusion, the Russian Ministry of Health guideline does not recommend inotropes: the potential benefit is smaller than the risk.<Cite n={1} /> Tachyarrhythmias are slowed by cardioversion or antiarrhythmic medicines, and bradycardia is treated with temporary pacing.<Cite n={5} />

The ESC 2026 guideline recommends a multidisciplinary Shock Team to guide the choice of temporary mechanical circulatory support (I C).<Cite n={3} /> A microaxial flow pump should be considered in selected patients with cardiogenic shock caused by STEMI, LV systolic dysfunction and no risk of hypoxic brain injury, to reduce the risk of death (IIa); in unselected patients with cardiogenic shock caused by acute MI, temporary mechanical support is not recommended because of the risk of harm, and intra-aortic balloon pumping is not recommended because of a lack of effect (III).<Cite n={3} /> The Russian Ministry of Health guideline describes mechanical support as a temporary "bridge" to revascularisation, surgery, heart transplantation or another decision.<Cite n={1} />

Even with treatment, mortality from cardiogenic shock after MI is 40–50%; the prognosis depends on the cause, pre-existing or complicating illness, the time between onset and diagnosis, and how promptly and adequately treatment is given.<Cite n={5} />

</Student>

## When to call an ambulance

Cardiogenic shock is always an emergency: people in shock need immediate emergency treatment, usually in an intensive care unit.<Cite n={7} /> Call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK) if a person with chest pain or known heart disease becomes sluggish, sleepy or confused, has cold, sweaty, pale or bluish skin, a weak rapid pulse or fast breathing, cannot sit up without feeling light-headed or fainting, or has almost stopped passing urine.<Cite n={[1, 7]} /> Do not wait for a low blood pressure reading: early in shock it may still be normal.<Cite n={7} /> In a heart attack it is important to recognise the signs quickly and call an ambulance straight away: in hospital the blocked artery can be opened urgently.<Cite n={1} /> The signs of a heart attack itself are described in [its article](../myocardial-infarction/).

If the person does not respond and is not breathing normally, this may be cardiac arrest: what to do until the ambulance arrives is described in the article on [ventricular fibrillation](../ventricular-fibrillation/).

<Quiz />