Management of cardiogenic shock: state-of-the-art

Christian Jung^{1

2}, Raphael Romano Bruno³, Marwan Jumean⁴, Susanna Price^{5

6}, Konstantin A Krychtiuk⁷, Kollengode Ramanathan^{8

9}, Josef Dankiewicz¹⁰, John French^{11

12

13}, Clement Delmas^{14

15}, Alexandra-Arias Mendoza¹⁶, Holger Thiele¹⁷, Sabri Soussi^{18

19}

Affiliations

¹ Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany. Christian.jung@med.uni-duesseldorf.de.
² Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany. Christian.jung@med.uni-duesseldorf.de.
³ Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany.
⁴ UTHealth McGovern Medical School, Houston, TX, USA.
⁵ Division of Heart, Lung and Critical Care, Royal Brompton Hospital, London, UK.
⁶ National Heart and Lung Institute, Imperial College London, London, UK.
⁷ Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria.
⁸ Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
⁹ Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore.
¹⁰ Department of Clinical Sciences Lund, Lund University, Cardiology, Lund, Sweden.
¹¹ Department of Cardiology, Liverpool Hospital, Sydney, Australia.
¹² School of Medicine, Western Sydney University, Sydney, Australia.
¹³ South Western Sydney Clinical School, The University of New South Wales, Sydney, Australia.
¹⁴ Intensive Cardiac Care Unit, Cardiology Department, Toulouse University Hospital, Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France.
¹⁵ REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France.
¹⁶ Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
¹⁷ Department of Internal Medicine/Cardiology and Leipzig Heart Science, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
¹⁸ Department of Anesthesia and Pain Management, University Health Network (UHN), Women's College Hospital, University of Toronto, Toronto Western Hospital, Toronto, Canada.
¹⁹ University of Paris Cité, Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Paris, France.

PMID: 39254735
PMCID: PMC11541372
DOI: 10.1007/s00134-024-07618-x

Review

Management of cardiogenic shock: state-of-the-art

Christian Jung et al. Intensive Care Med. 2024 Nov.

. 2024 Nov;50(11):1814-1829.

doi: 10.1007/s00134-024-07618-x. Epub 2024 Sep 10.

Authors

Affiliations

¹ Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany. Christian.jung@med.uni-duesseldorf.de.
² Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany. Christian.jung@med.uni-duesseldorf.de.
³ Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany.
⁴ UTHealth McGovern Medical School, Houston, TX, USA.
⁵ Division of Heart, Lung and Critical Care, Royal Brompton Hospital, London, UK.
⁶ National Heart and Lung Institute, Imperial College London, London, UK.
⁷ Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria.
⁸ Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
⁹ Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore.
¹⁰ Department of Clinical Sciences Lund, Lund University, Cardiology, Lund, Sweden.
¹¹ Department of Cardiology, Liverpool Hospital, Sydney, Australia.
¹² School of Medicine, Western Sydney University, Sydney, Australia.
¹³ South Western Sydney Clinical School, The University of New South Wales, Sydney, Australia.
¹⁴ Intensive Cardiac Care Unit, Cardiology Department, Toulouse University Hospital, Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France.
¹⁵ REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France.
¹⁶ Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
¹⁷ Department of Internal Medicine/Cardiology and Leipzig Heart Science, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
¹⁸ Department of Anesthesia and Pain Management, University Health Network (UHN), Women's College Hospital, University of Toronto, Toronto Western Hospital, Toronto, Canada.
¹⁹ University of Paris Cité, Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Paris, France.

PMID: 39254735
PMCID: PMC11541372
DOI: 10.1007/s00134-024-07618-x

Abstract

The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.

Keywords: Assist device; Cardiogenic shock; Heart failure; Intensive care; Myocardial infarction; Outcome.

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Conflict of interest statement

CJ reports institutional grants by the German research foundation, German ministry for economy and energy, State of Nordrhine-Westfalia, German space agency, European Union and Edwards Lifescience as well as speaker fees outside the field of this article by Bristol Myers Squibb, Daichi Sankyo and Boehringer-Ingelheim. RRB: no conflict of interest. MJ: no conflict of interest. SP: no conflict of interest. KAK reports speaker fees received from Daiichi Sankyo, Zoll Medical, Amarin, consulting fees by Amarin, Novartis, Sanofi and travel support provided by Amgen, Sanofi and Daiichi Sankyo. KR reports that he is the current Chair of Publications at the Extracorporeal Life Support Organisation. JD: no conflict of interest. JF: no conflict of interest. Clement Delmas reports lectures and consulting fees received by Abiomed and Abott. A-AM: no conflict of interest. HT: no conflict of interest. SS: no conflict of interest.

Figures

**Fig. 1**
Summary of the traditional (clinical), current/emerging (SCAI shock stages), and future approaches (biomarker-driven phenotypes) to unravel CS heterogeneity. CS cardiogenic shock, *SCAI* Society for Cardiovascular Angiography and Interventions

**Fig. 2**
Therapeutic strategies, pharmacologic mechanisms, and potential treatment targets in cardiogenic shock. *AMP* Adenosine Monophosphate, *Beta 1* β1 Adrenergic Receptor, *cAMP* Cyclic Adenosine Monophosphate, *cGMP* Cyclic Guanosine Monophosphate, *DAG* Diacylglycerol; Gs α- Stimulatory G protein α subunit, *Gs β/γ* Stimulatory G protein β/γ subunit, *Gq α* Gq alpha subunit, *Gq β/γ* Gq beta/gamma subunit, *IP3* Inositol Trisphosphate, *PDE-III* Phosphodiesterase-III, V1 Vasopressin receptor subtype 1 (V1 receptor), *α1-Receptor* α-1 Adrenergic Receptor

**Fig. 3**
Mechanical circulatory support devices. Right-ventricular (upper panel) and left-ventricular assist devices (lower panel). In biventricular failure assist, a combination of devices might be used. ECMELLA, the combination of VA-ECMO and Impella, serves as LV support and LV unloading strategy. RA right atrium, PA pulmonary artery, VA venoarterial (configuration), *ECMO* extracorporeal membrane oxygenation, *IABP* intra-aortic balloon pump, F French (1F = 0.33 mm), RV right-ventricular, LV left-ventricular

See this image and copyright information in PMC

References

1. Waksman R et al (2023) Standardized definitions for cardiogenic shock research and mechanical circulatory support devices: scientific expert panel from the shock Academic Research Consortium (SHARC). Circulation 148(14):1113–1126 - PMC - PubMed
1. van Diepen S et al (2017) Contemporary management of cardiogenic shock: a scientific statement from the american heart association. Circulation 136(16):e232–e268 - PubMed
1. Herrick JB (1983) Clinical features of sudden obstruction of the coronary arteries. JAMA 250(13):1757–1762 - PubMed
1. Stead EA, Ebert RV (1942) Shock syndrome produced by failure of the heart. Arch Inter Med 69(3):369–383
1. Zeymer U et al (2020) Acute cardiovascular care association position statement for the diagnosis and treatment of patients with acute myocardial infarction complicated by cardiogenic shock: a document of the acute cardiovascular care association of the European Society of Cardiology. Eur Heart J Acute Cardiovasc Care 9(2):183–197 - PubMed

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Management of cardiogenic shock: state-of-the-art

Affiliations

Management of cardiogenic shock: state-of-the-art

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

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