The Contemporary Cardiogenic Shock ‘Playbook’

Register or Login to View PDF Permissions
Permissions× For commercial reprint enquiries please contact Springer Healthcare: ReprintsWarehouse@springernature.com.

For permissions and non-commercial reprint enquiries, please visit Copyright.com to start a request.

For author reprints, please email rob.barclay@radcliffe-group.com.
Information image
Average (ratings)
No ratings
Your rating

Disclosure:AGT is a consultant and member of the speakers bureau for Abiomed, and is Guest Editor of the cardiogenic shock special collection for US Cardiology Review.



Published online:

Correspondence Details:Alexander G Truesdell, Virginia Heart/Inova Heart and Vascular Institute, 2901 Telestar Court, Falls Church, VA 22042. E: agtruesdell@gmail.com

Open Access:

This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

“You can’t really know where you are going until you know where you have been.”

– Maya Angelou1

Cardiogenic shock (CS) is a state of end-organ hypoperfusion and dysfunction, often complicated by a systemic inflammatory response, due to insufficient cardiac output despite adequate preload, secondary to left ventricular, right ventricular, or biventricular dysfunction. CS typically occurs in the setting of acute MI or acute decompensated heart failure, with or without cardiac arrest, and accounts for nearly 15% of all cardiac intensive care unit admissions.2 Inpatient mortality rates, once as high as 90%, remain elevated near 50% despite several decades of advances in pharmacological and device-based therapies, highlighting multiple unmet needs and unachieved goals in the diagnosis and management of this deadly condition.3

Complex, multidimensional, and resource-intensive problems, such as CS, typically require an organized approach to diagnosis, treatment, monitoring, and recovery. Due to the highly time-sensitive morbidity and mortality of CS, diagnosis and therapies must also be expeditious. A CS ‘playbook’ (Figure 1) may, therefore, aid individuals and teams to: visualize targets, identify capabilities and gaps, articulate critical elements for success, and distill strategies down to actionable component tasks with clearly defined individual and group roles and responsibilities to achieve desired end goals.4

“Shock is the manifestation of the rude unhinging of the machinery of life.”

– Samuel V Gross5

The complexities of the shock syndrome, delays in illness recognition, inconsistencies in phenotype and severity definitions, barriers to access to potentially disease-modifying interventions, and undesired heterogeneities of care both within and between medical facilities all likely contribute to the persistent lethality of CS.6 The presence of multiple converging paths to death with both shock-related and shock-independent factors – to include age, cardiac arrest, organ failure, anoxic brain injury, and bleeding – also further complicate efforts to reduce disease morbidity and mortality.

In this special collection of US Cardiology Review, published contemporaneously with the multidisciplinary international SCAI Shock 2021 Virtual conference (https://scai.org/shock), a collection of worldwide multispecialty experts address the optimal contemporary ‘playbook’ for CS prevention, diagnosis, management, and research to include: advocacy and legislative initiatives, drug and device development, diagnostic frameworks and modalities, therapeutic technologies, multidisciplinary systems of care, cardiac intensive care unit management strategies, rescue and replacement innovations, ongoing clinical research efforts, and future outlook for the field.

“Without good data, we’re flying blind. If you can’t see it, you can’t solve it.”

– Kofi Annan7

Therapeutic decision-making, and appropriate drug and device selection are influenced by pre-shock cardiovascular state, extracardiac comorbidities, shock etiology and phenotype, severity of illness, and the presence or absence of concomitant respiratory failure and/or cardiac arrest. There remains much uncertainty regarding the appropriate definitions, identification, and optimal management of different etiologies, phenotypes, and stages of CS – to include appropriate targets of metabolic tissue perfusion and pump function, and preferred modalities, combinations, and sequence of pharmacological and device-based therapies.8

Shock states often encompass intersecting acute MI, acute decompensated heart failure, post-cardiotomy, pulmonary embolism, cardiac arrest, and valvular heart disease-related entities with etiology-specific risk-related classifications and invasive hemodynamic profiles. Understanding the relationships between disease acuity and severity, hemodynamic phenotypes, age, extracardiac organ involvement, and underlying comorbidities and pre-existing chronic illness, while challenging, is key to successful management.

As shock is a rapidly evolving condition, full-spectrum management requires vigilance and an “unblinking eye” approach to monitoring and therapy across an often prolonged and highly dynamic clinical course. Optimal tailored care necessitates constant hemodynamic situational awareness guided by serial measured and derived hemodynamic parameters to frequently profile and repeatedly re-profile shock states to track clinical trajectories, and guide appropriate weaning and escalation of therapies.9 Optimal management additionally requires detailed and systematic assessments of non-cardiac organ systems, balancing the risks and benefits of individual medical investigations and interventions, while simultaneously surveilling, preventing, and managing the many complications associated with critical illness.10

Key Components of Optimal Contemporary Multidisciplinary Cardiogenic Shock Diagnosis, Management, and Research Initiatives

Article image

“Coming together is the beginning. Keeping together is progress. Working together is success.”

– Henry Ford

Patients in CS often deteriorate rapidly, and as shock persists, end-organ hypoperfusion, ischemia, and acidosis worsen, often irreversibly. Successful diagnostic and therapeutic decision-making must, therefore, be both timely and rapidly effective. Use of newer advanced therapies and various forms of mechanical circulatory support often require the coordinated efforts of multiple medical specialists – to include interventional cardiologists, cardiothoracic surgeons, advanced heart failure specialists, and cardiac intensivists.

Multidisciplinary team-based, protocol-driven CS care has demonstrated promising potential to improve clinical outcomes beyond the historical 50% glass ceiling of the past three decades.11 Despite recent consensus efforts to standardize definitions, the complex hemodynamics and variable clinical phenotypes of the CS syndrome mean that the diagnosis and management of CS remains challenging, and often requires expertise across a range of medical specialties.12 Modern multidisciplinary CS teams are designed to enhance the individual strengths of component team members, streamline care delivery, and reduce care variability and disparities to optimize outcomes for these medically complex and resource-intensive patients. The Venn diagram of optimal management thus lies at the crossroads of multiple collaborating cardiovascular and non-cardiovascular specialists working together as a “team of teams.”

At the regional level and beyond, it is critical that big and small community hospitals, academic medical centers, and health systems partner for early identification and stabilization of CS patients with expedited follow-on consultation and/or transfer for definitive management. Intra- and interinstitutional case and process reviews are critical to identify successes, failures, opportunities for improvement, and specific tasks and timelines to become continuously learning and improving organizations.

“Look to the future because that’s where you’ll spend the rest of your life.”

– George Burns

Five key treatment objectives have been increasingly promoted in the acute management of CS: circulatory support, ventricular support, myocardial perfusion, decongestion, and prevention and management of extracardiac critical illness. Although the optimal recipe for successful management of acute MI and acute decompensated heart failure CS remains to be discovered, thus far the “playbook” appears to be: appropriate patient selection and triage, hemodynamically guided diagnosis and treatment, dynamic management algorithms and protocols, combined pharmacological and device therapies, and collaborative multidisciplinary team-based cardiac intensive care unit care.13

Beyond initial stabilization and management strategies, we must continue to pursue ongoing innovations in chronic heart failure pharmacological therapies, as well as temporary and durable ventricular assistance and heart transplantation to maximize heart recovery, reduce symptoms, prevent sudden cardiac death, and provide feasible options for non-recoverable patients.14,15 There is also a parallel need for legislative efforts to develop structured local and regional shock care networks with a tiered model for care delivery for this sickest population of cardiac patients.16

While clinical trials that evaluate drugs, devices, and best practices for CS have been challenging to conduct and slow to enroll, they remain critically important to scientific progress. Barriers to generating high-quality evidence include: non-standardized definitions of CS, heterogeneity of study inclusion criteria, the rapid lethality of CS and associated time-sensitivity of diagnostic and therapeutic interventions, multiplicity of pathways to death, overlapping interactions of technologies and systems of care, and difficulties in achieving informed consent in emergency conditions and situations. Looking forward, we must continue to work collectively to overcome these barriers to generating high-quality evidence.3,17 Although the journey may be long, the destination is vitally important to us all.


  1. America’s Renaissance Woman. Academy of Achievement. January 22, 1997. https://achievement.org/achiever/maya-angelou/#interview (accessed November 12, 2021).
  2. Berg DD, Bohula EA, van Diepen S, et al. Epidemiology of shock in contemporary cardiac intensive care units. Circ Cardiovasc Qual Outcomes 2019;12:e005618.
    Crossref | PubMed
  3. Samsky M, Krucoff M, Althouse AD, et al. Clinical and regulatory landscape for cardiogenic shock: a report from the Cardiac Safety Research Consortium ThinkTank on cardiogenic shock. Am Heart J 2020;219:1–8.
    Crossref | PubMed
  4. Truesdell AG, Tehrani D, Singh R, et al. ‘Combat’ approach to cardiogenic shock. Interv Cardiol 2018;13:81–6.
    Crossref | PubMed
  5. Gross SG. A System of Surgery: Pathological, Diagnostic, Therapeutic, and Operative. Philadelphia: Lea & Febiger, 1872.
  6. Vallabhajosyula S, Dunlay SM, Barsness GW, et al. Hospital-level disparities in the outcomes of acute myocardial infarction with cardiogenic shock. Am J Cardiol 2019;124:491–8.
    Crossref | PubMed
  7. Annan K. Data can help to end malnutrition across Africa. Nature 2018;555:7.
    Crossref | PubMed
  8. van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation 2017;136:e232–68.
    Crossref | PubMed
  9. Thayer KL, Zweck E, Ayouty M, et al. Invasive hemodynamic assessment and classification of in-hospital mortality risk among patients with cardiogenic shock. Circ Heart Fail 2020:13:e007099.
    Crossref | PubMed
  10. Fordyce CB, Katz JN, Alviar CL, et al. Prevention of complications in the cardiac intensive care unit: a scientific statement from the American Heart Association. Circulation 2020;142:e379–406.
    Crossref | PubMed
  11. Moghaddam N, van Deipen S, So D, et al. Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock. ESC Heart Fail 2021;8:988–98.
    Crossref | PubMed
  12. Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv 2019;94:29–37.
    Crossref | PubMed
  13. Tehrani BN, Truesdell AG, Psotka MA, et al. A standardized and comprehensive approach to the management of cardiogenic shock. JACC Heart Fail 2020;8:879–91.
    Crossref | PubMed
  14. Writing Committee; Maddox TM, Jannuzi Jr JL, et al. 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021;77:772–810.
    Crossref | PubMed
  15. Miller L, Birks E, Guglin M, et al. Use of ventricular assist devices and heart transplantation for advanced heart failure. Circ Res 2019;124:1658–78.
    Crossref | PubMed
  16. Tchantchaleishvili V, Hallinan W, Massey HT. Call for organized statewide networks for management of acute myocardial infarction-related cardiogenic shock. JAMA Surg 2015;150:1025–6.
    Crossref | PubMed
  17. Arrigo M, Price S, Baran DA, et al. Optimising clinical trials in acute myocardial infarction complicated by cardiogenic shock: a statement from the 2020 Critical Care Clinical Trialists Workshop. Lancet Respir Med 2021;9:1192–1201.
    Crossref | PubMed