Diseases > Cardiogenic shock

The following summarized guidelines for the evaluation and management of cardiogenic shock are prepared by our editorial team based on guidelines from the Heart Failure Society of America (HFSA/AHA/ACC 2022), the European Society of Cardiology (ESC 2021), and the American Heart Association (AHA/ACC 2013).

1. Diagnostic procedures

Pulmonary artery catheterization:

consider placing a pulmonary artery line to define hemodynamic subsets and appropriate management strategies in patients presenting with cardiogenic shock.

Coronary angiography:

transfer suitable patients with STEMI developing cardiogenic shock or acute severe HF, irrespective of the time delay from myocardial infarction onset, immediately to a PCI-capable hospital for coronary angiography.

2. Medical management

General principles

consider managing patients with cardiogenic shock by a multidisciplinary team experienced in shock.

Inotropes

administer IV inotropic support to maintain systemic perfusion and preserve end-organ performance in patients with cardiogenic shock.

Vasopressors

consider administering a vasopressor, preferably norepinephrine, to increase BP and vital organ perfusion in patients with cardiogenic shock.

Fibrinolytic therapy

administer fibrinolytic therapy, in the absence of contraindications, in patients with STEMI and cardiogenic shock unsuitable for either PCI or CABG.

3. Therapeutic procedures

Mechanical circulatory support:

• As per ACC 2022 guidelines:Consider triaging patients not rapidly responding to initial shock measures to centers providing temporary mechanical circulatory support to optimize management.Consider initiating temporary mechanical circulatory support in patients with cardiogenic shock when end-organ function cannot be maintained by pharmacologic means to support cardiac function.
• As per ESC 2021 guidelines, consider initiating short-term mechanical circulatory support in patients with cardiogenic shock as a bridge to recovery, bridge to decision, bridge to bridge or to treat the cause of cardiogenic shock or long-term mechanical circulatory support or transplantation.

Mechanical circulatory support (ACCF):

consider performing placement of alternative LV assist devices for circulatory support in patients with refractory cardiogenic shock.

Intra-aortic balloon pump:

• As per ESC 2021 guidelines:Consider performing intra-aortic balloon pump therapy in patients with cardiogenic shock as a bridge to recovery, bridge to decision, bridge to bridge including the treatment of cardiogenic shock (mechanical complication of acute myocardial infarction) or long-term mechanical circulatory support or transplantation.Do not perform intra-aortic balloon pump therapy routinely in patients with post-myocardial infarction cardiogenic shock.

Intra-aortic balloon pump (ACCF):

consider performing intra-aortic balloon pump counterpulsation in patients with cardiogenic shock after STEMI not quickly stabilized with pharmacological therapy.

Coronary revascularization:

revascularization: perform emergency revascularization with either PCI or CABG in suitable patients with cardiogenic shock due to pump failure after STEMI irrespective of the time delay from myocardial infarction onset.