Cardiogenic shock (CS), defined as forward failure combined with systolic blood pressure < 90 mm Hg and reduced organ perfusion despite adequate volume loading, still has a grim prognosis with mortality rates of 80-100% if the causes are left untreated. The most frequent conditions underlying CS are acute myocardial infarction, acute and severe aortic or mitral incompetence, rapidly progressive dilatative cardiomyopathy and hypertrophic obstructive cardiomyopathy. Whereas correct conservative management by drugs and pacing may be life saving in the latter, the other conditions require early invasive management. Indications for cardiac surgery and circulatory assistance are given for mechanical complications leading to CS. In CS complicating myocardial infarction, comprehensive management with early invasive revascularization and intraaortic balloon pumping may result in improved survival compared with the disappointing outcome of medical treatment, including fibrinolysis. This strategy can be offered to the majority of infarct patients in CS, who are primarily admitted to hospitals not equipped for interventional cardiology or cardiac surgery. Between-hospital transfer of these patients for PTCA (or surgery) and advanced intensive care has been shown to be feasible and safe.