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Review
. 2023 Sep 1;51(9):1222-1233.
doi: 10.1097/CCM.0000000000005919. Epub 2023 May 15.

Advances in the Management of Cardiogenic Shock

Jacob C Jentzer  1 , Janine Pöss  2 , Hannah Schaubroeck  3 , David A Morrow  4 , Steven M Hollenberg  5 , Alexandre Mebazaa  6
Affiliations
Review

Advances in the Management of Cardiogenic Shock

Jacob C Jentzer et al. Crit Care Med. .

Abstract

Objectives: To review a contemporary approach to the management of patients with cardiogenic shock (CS).

Data sources: We reviewed salient medical literature regarding CS.

Study selection: We included professional society scientific statements and clinical studies examining outcomes in patients with CS, with a focus on randomized clinical trials.

Data extraction: We extracted salient study results and scientific statement recommendations regarding the management of CS.

Data synthesis: Professional society recommendations were integrated with evaluated studies.

Conclusions: CS results in short-term mortality exceeding 30% despite standard therapy. While acute myocardial infarction (AMI) has been the focus of most CS research, heart failure-related CS now predominates at many centers. CS can present with a wide spectrum of shock severity, including patients who are normotensive despite ongoing hypoperfusion. The Society for Cardiovascular Angiography and Intervention Shock Classification categorizes patients with or at risk of CS according to shock severity, which predicts mortality. The CS population includes a heterogeneous mix of phenotypes defined by ventricular function, hemodynamic profile, biomarkers, and other clinical variables. Integrating the shock severity and CS phenotype with nonmodifiable risk factors for mortality can guide clinical decision-making and prognostication. Identifying and treating the cause of CS is crucial for success, including early culprit vessel revascularization for AMI. Vasopressors and inotropes titrated to restore arterial pressure and perfusion are the cornerstone of initial medical therapy for CS. Temporary mechanical circulatory support (MCS) is indicated for appropriately selected patients as a bridge to recovery, decision, durable MCS, or heart transplant. Randomized controlled trials have not demonstrated better survival with the routine use of temporary MCS in patients with CS. Accordingly, a multidisciplinary team-based approach should be used to tailor the type of hemodynamic support to each individual CS patient's needs based on shock severity, phenotype, and exit strategy.

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Conflict of interest statement

Dr. Pöss receives research funding from the German Cardiac Society, German Heart Research Foundation, and Dr. Rolf M. Schwiete Foundation. Dr. Schaubroeck has received honoraria from Abiomed. Dr. Morrow’s institution received funding from Abbott, Abiomed, and Amgen; he disclosed that he is a member of the Thrombolysis in Myocardial Infarction Study Group, which has received institutional research grant support through Brigham and Women’s Hospital from: Abbott, Amgen, Anthos Therapeutics, ARCA Biopharma, AstraZeneca, Bayer HealthCare Pharmaceuticals, Daiichi-Sankyo, Eisai, Intarcia, Ionis Pharmaceuticals, Janssen Research and Development, LLC, Merck, Novartis, Pfizer, Quark Pharmaceuticals, Regeneron Pharmaceuticals, Roche, Siemens Healthcare Diagnostics, Softcell Medical Limited, and Zora Biosciences. He has received consulting fees from Abbott Laboratories, ARCA Biopharma, InCardia, Inflammatix, Merck & Co, Novartis, and Roche Diagnostics. Dr. Mebazaa received grant from Roche Diagnostics, Abbott Laboratories, 4TEEN4, and WIndtree Therapeutics; he received honoraria for lectures from Roche Diagnostics, Bayer, and MSD; he is a consultant for Corteria Pharmaceuticals, S-Form Pharma, FIRE-1, Implicity, 4TEEN4, and Adrenomed; he is coinventor of a patent on combination therapy for patients having acute and/or persistent dyspnea; and he disclosed the off-label product use of Vasopressors and specific mechanical circulatory support devices may not be labeled for use in shock. The remaining authors have disclosed that they do not have any potential conflicts of interest.

References

    1. van Diepen S, Katz JN, Albert NM, et al.; American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Mission: Lifeline: Contemporary management of cardiogenic shock: A scientific statement from the American Heart Association. Circulation. 2017; 136:e232–e268
    1. Chioncel O, Parissis J, Mebazaa A, et al.: Epidemiology, pathophysiology and contemporary management of cardiogenic shock - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2020; 22:1315–1341
    1. Osman M, Syed M, Patibandla S, et al.: Fifteen-year trends in incidence of cardiogenic shock hospitalization and in-hospital mortality in the United States. J Am Heart Assoc. 2021; 10:e021061
    1. Esposito ML, Kapur NK: Acute mechanical circulatory support for cardiogenic shock: The “door to support” time. F1000Res. 2017; 6:737
    1. Tyler JM, Brown C, Jentzer JC, et al.: Variability in reporting of key outcome predictors in acute myocardial infarction cardiogenic shock trials. Catheter Cardiovasc Interv. 2022; 99:19–26

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