What is the management of cardiogenic shock?

Management of Cardiogenic Shock

Cardiogenic shock requires a standardized approach focused on rapid diagnosis, early intervention, ongoing hemodynamic assessment, and multidisciplinary longitudinal care to reduce mortality rates that currently exceed 40%. 1, 2

Diagnosis and Initial Assessment

• Clinical criteria for cardiogenic shock include SBP <90 mmHg for 30 minutes or requiring inotropes/vasopressors to maintain SBP >90 mmHg, evidence of end-organ hypoperfusion, and lactate >2 mmol/L 2, 3
• Hemodynamic criteria include cardiac index <1.8 L/min/m² without vasopressors/inotropes and cardiac power output <0.6 W 2, 3
• Immediate comprehensive assessment with ECG and echocardiography is essential for all patients with suspected cardiogenic shock 3
• Establish invasive monitoring with arterial line for accurate blood pressure measurement and sampling 3
• Early invasive hemodynamic assessment with pulmonary artery catheter is recommended to identify the specific cardiogenic shock phenotype and guide therapy 1, 3
• Classify severity using the Society for Cardiovascular Angiography and Interventions (SCAI) 5-stage (A-E) classification system to guide treatment decisions 3, 4

Immediate Management Steps

• Perform fluid challenge (saline or ringer lactate, >200 ml/15-30 min) as first-line treatment if there are no signs of overt fluid overload 3
• In AMI-related cardiogenic shock, perform immediate coronary angiography (within 2 hours) with intent to revascularize 3, 4
• For patients with SCAI stage C or D cardiogenic shock, provide initial stabilization with vasopressor therapy and mechanical ventilation before revascularization 3
• For patients with SCAI stage E (end-stage) cardiogenic shock, consider palliative care consultation 3

Pharmacological Management

• Norepinephrine is the preferred first-line vasopressor agent when mean arterial pressure needs pharmacologic support 2, 3
• Vasopressin (0.01 to 0.07 units/minute for septic shock; 0.03 to 0.1 units/minute for post-cardiotomy shock) can be used as an adjunct to norepinephrine to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines 5
• Dobutamine (2-20 μg/kg/min) is the first-line inotropic agent to increase cardiac output 2, 3
• Milrinone may be considered as an alternative to dobutamine, particularly in patients on beta-blockers 3

Phenotype-Specific Management

• For LV-dominant cardiogenic shock: Consider dobutamine or milrinone to improve cardiac output 3
• For RV-dominant cardiogenic shock: Consider agents that increase systemic afterload without increasing pulmonary vascular resistance (vasopressin, norepinephrine) to maintain RV perfusion; minimize intrathoracic positive pressure ventilation, correct acidosis, and improve oxygenation 2, 3
• For biventricular cardiogenic shock: Consider combination therapy tailored to hemodynamic parameters 3
• For normotensive hypoperfusion: Consider vasodilators such as nitroprusside to improve cardiac output by reducing afterload 2, 3

Mechanical Circulatory Support (MCS)

• Consider short-term mechanical circulatory support in refractory cardiogenic shock based on patient age, comorbidities, and neurological function 3, 6
• Routine use of intra-aortic balloon pump (IABP) in cardiogenic shock is not recommended 3
• For RV failure, consider RV-specific mechanical support devices (Impella RP, Protek Duo) 3
• For progressive pulmonary hypertension with RV failure, venoarterial extracorporeal membrane oxygenation may be preferred 3
• Temporary MCS is indicated for appropriately selected patients as a bridge to recovery, decision, durable MCS, or heart transplant 4
• Randomized controlled trials have not demonstrated better survival with the routine use of temporary MCS in patients with cardiogenic shock 4

Special Considerations

• In cardiogenic shock due to valvular disease, emergency cardiac surgery is the gold standard treatment 3, 7
• For arrhythmia-induced cardiogenic shock, prioritize restoration of sinus rhythm 3
• In atrial fibrillation with cardiogenic shock, amiodarone is the most efficient and safest agent for cardioversion 3
• The economic impact of cardiogenic shock is substantial, especially when accompanied by multiorgan system failure, which is associated with nearly 50% in-hospital mortality, longer lengths of stay, and greater resource utilization 1

System-Based Approach

• Transfer patients with cardiogenic shock to a tertiary care center with 24/7 cardiac catheterization capability and mechanical circulatory support availability 3, 8
• Implement a multidisciplinary shock team approach for complex cases 2, 3
• Develop shock networks with regionalized systems of care to improve clinical outcomes 3, 9
• Utilize a phased approach to management: Rescue, Optimization, Stabilization, and de-Escalation or Exit therapy (R-O-S-E) 9