Cardiogenic shock as a result of myocardial infarction demands an aggressive diagnostic and therapeutic approach to improve survival. First, the patient likely to develop shock should be identified early in his course so that interventions to reduce or contain infarct progression and thus prevent shock can be instituted. If the patient's condition deteriorates, prompt precise diagnosis of the cause of the hemodyanamic impairment must be made at the bedside with Swan-Ganz right heart catheterization and echocardiography, and, if potentially surgically correctable disease is present, left heart catheterization with coronary angiography in the catheterization laboratory should be done. Surgical repair of anatomic disruptions of the heart ventricular septal defect, or mitral valve rupture is frequently life-saving. At present, operative intervention for shock secondary to massive myocardial infarction alone remains a challenge.