A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock

Abstract

Cardiogenic shock is a hemodynamically complex syndrome characterized by a low cardiac output that often culminates in multiorgan system failure and death. Despite recent advances, clinical outcomes remain poor, with mortality rates exceeding 40%. In the absence of adequately powered randomized controlled trials to guide therapy, best practices for shock management remain nonuniform. Emerging data from North American registries, however, support the use of standardized protocols focused on rapid diagnosis, early intervention, ongoing hemodynamic assessment, and multidisciplinary longitudinal care. In this review, the authors examine the pathophysiology and phenotypes of cardiogenic shock, benefits and limitations of current therapies, and they propose a standardized and team-based treatment algorithm. Lastly, they discuss future research opportunities to address current gaps in clinical knowledge.

Keywords: acute decompensated heart failure; acute myocardial infarction; cardiogenic shock; mechanical circulatory support; multidisciplinary care.

FIGURE 1. Pathophysiology of Cardiogenic Shock

Cardiogenic shock is a Low-output state stemming from primary cardiac dysfunction, resulting in hypotension and systemic hypoperfusion. This maladaptive syndrome is perpetuated by physiologic cycles of inflammation, ischemia, vasoconstriction, and volume overload.

FIGURE 2. Current Mechanical Circulatory Support Devices Used for the Treatment of Cardiogenic Shock

The hemodynamic profiles of the various circulatory support devices available for treatment of cardiogenic shock. ADHF = acute decompensated heart failure; AMI = acute myocardial infarction; AO = aorta; Bi-V = biventricular; CS = cardiogenic shock; FA = femoral artery; FDA = Food and Drug Administration; HR-PCI = high risk percutaneous coronary intervention; IABP = intra-aortic balloon pump; IJ = internal jugular; LA = left atrium; LV = left ventricular; LVAD = left ventricular assist device; PA = pulmonary artery; RA = right atrium; RPM = revolutions per minute; RV = right ventricular; RVF = right ventricular failure; VA-ECMO = venoarterial extracorporeal membrane oxygenation. Adapted with permission from Thiele et al. (15).

FIGURE 3. CICU Management of CS

This schematic illustrates the longitudinal and multidisciplinary care pathways for cardiogenic shock (CS) care in a contemporary level 1 cardiac intensive care unit (CICU). CI = cardiac index; CO = cardiac output; CPO = cardiac power output; DNR = Do Not Resuscitate order; dPAP = diastolic pulmonary arterial pressure; L = left; MAP = mean arterial pressure; MCS = mechanical circulatory support; PAPi = pulmonary arterial pulsatility index; PCWP = pulmonary capillary wedge pressure; pVAD = percutaneous ventricular assist device; R = right; sPAP = systolic pulmonary arterial pressure; other abbreviations as in Figure 2.

CENTRAL ILLUSTRATION. Proposed Pathway for Contemporary Shock Care

Schematic representation of a proposed pathway for cardiogenic shock (CS) management. Key components include timely recognition, early invasive hemodynamics and selective and tailored circulatory support. Regionalized systems of care with multidisciplinary CS teams can aid in the triage and transfer of these patients to dedicated Level 1 CS centers for full spectrum and longitudinal care. ADHF-CS = acute decompensated heart failure complicated by cardiogenic shock; AMI-CS = acute myocardial infarction complicated by cardiogenic shock; CI = cardiac index; CICU = cardiac intensive care unit; CPO = cardiac power output; IABP = intra-aortic balloon pump; PAPi = pulmonary arterial pulsatility index; PCWP = pulmonary capillary wedge pressure; SBP = systolic blood pressure; VA-ECMO = venoarterial extracorporeal membrane oxygenation.