A 72-year-old patient is in cardiogenic shock post-MI with refractory hypotension. Which vasopressor/inotrope combination best balances increasing MAP while avoiding excessive tachycardia and increased myocardial oxygen demand?

• A High-dose dopamine alone (15–20 μg/kg/min)
• B Epinephrine alone at maximum doses
• C Phenylephrine alone to raise SVR and MAP
• D Norepinephrine (to raise MAP via α1) combined with dobutamine (to increase cardiac output via β1) ✓

Explanation

In cardiogenic shock, the goal is to improve both MAP (to maintain coronary perfusion) and cardiac output. Norepinephrine (predominantly α1 with some β1) effectively raises MAP via vasoconstriction with less tachycardia than epinephrine or high-dose dopamine. Adding dobutamine addresses the low cardiac output by β1-mediated inotropy. Pure phenylephrine raises afterload without improving contractility, worsening the failing heart. High-dose dopamine causes excessive tachycardia and arrhythmias.

Reference: KD Tripathi, Essentials of Medical Pharmacology, 8th ed.

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