Asian Journal of Medical Research and Case Reports

Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to severe cardiac dysfunction and remains associated with high mortality despite advances in pharmacologic and device-based support. This case series describes four male patients (aged 50–72 years) with CS complicated by extensive comorbidity, including coronary artery disease, dilated cardiomyopathy, Type 2 diabetes mellitus, and chronic kidney disease, and markedly reduced left ventricular ejection fraction (28–30% in two cases). All patients presented with profound hypotension (blood pressure as low as 80/50 mmHg) and clinical evidence of hemodynamic collapse, necessitating urgent vasoactive support. Noradrenaline was employed as the primary vasopressor in all cases, with careful titration of continuous intravenous infusion to restore mean arterial pressure and improve perfusion, consistent with contemporary recommendations that favour norepinephrine over dopamine as first-line therapy in CS. In two patients, noradrenaline was combined with dopamine to augment inotropy in the setting of refractory hypotension. Management was further complicated by renal dysfunction, heart failure, and coagulation abnormalities, requiring repeated optimisation of background therapies, including de-escalation of dual antiplatelet therapy, adjustment of renin–angiotensin system blockade, and active correction of anaemia. Across cases, haemodynamic stabilisation was achieved through individualized titration of vasopressors alongside multidisciplinary optimisation of cardiovascular, renal, and metabolic status. These findings suggest that noradrenaline can serve as an effective first-line vasopressor for initial hemodynamic stabilization in complex cardiogenic shock, particularly when integrated with multidisciplinary and individualized patient management strategies. This series highlights the central role of goal-directed noradrenaline therapy in the acute resuscitation of complex CS and underscores the importance of pharmacist-supported, patient-specific adjustments to chronic cardiovascular and nephroprotective regimens in improving clinical trajectories in this high-risk population.