Cardiogenic Shock 2024–2025 — Keynotes from Global Guidelines
Cardiogenic Shock 2024–2025 — Keynotes from Global Guidelines
The most recent international updates on the management of cardiogenic shock (CS) are drawn from the ACC/AHA Clinical Guidance 2025, ISHLT Consensus 2024, the ESC ACS Update 2023, and the SCAI Shock Staging Framework 2022
Keynotes:
1. Levels of Care (AHA/ACC – Heart Failure Centers Framework, adapted for Shock Care)
• Level 1 – Foundation / Basic:
• Provides only initial stabilization (fluids, vasopressors, inotropes).
• Basic monitoring and referral pathways.
• Level 2 – Advanced:
• PCI-capable hospital and short-term possible MCS = Mechanical Circulatory Support devices (IABP, Impella, TandemHeart).
• Can perform emergency revascularization and temporary circulatory support.
• No durable LVAD or transplant programs.
• Level 3 – Comprehensive / Hub:
• High-volume referral center.
• Full advanced therapies: durable LVAD, BiVAD, heart transplantation.
• 24/7 multidisciplinary “Shock Team” (cardiology, cardiac surgery, ICU, perfusion).
• Research and training integrated.
2. ISHLT Consensus (International Society for Heart and Lung Transplantation)
2024 – Key Messages:
• Cardiogenic shock exists on a continuum, classified by the SCAI stages A–E.
• Stage A: At risk – patient has acute coronary syndrome or decompensated HF but no shock yet.
• Stage B: Beginning – early signs of shock (mild hypotension, tachycardia).
• Stage C: Classic – clear hypotension with hypoperfusion (cold extremities, oliguria, high lactate).
• Stage D: Deteriorating – worsening shock despite fluids, vasopressors, or inotropes.
• Stage E: Extremis – circulatory collapse or cardiac arrest.
Treatment intensity must match severity: simple support in early stages, escalating to advanced therapies and MCS in later stages.
• Checklists before transfer (vitals, labs, echo, therapies, shock stage) save critical time.
• End-organ perfusion (brain, kidney, liver) is the ultimate therapeutic goal—not a fixed blood Bp target.
• Anticoagulation with temporary MCS must be individualized:
• Impella: continuous heparin flush through the device + systemic anticoagulation.
• ECMO: continuous IV heparin with ACT/aPTT monitoring.
• Timing: highest thrombus risk during the first 24–48 hours after device insertion.
3. ACC/AHA 2025 Guidelines — ACS and Cardiogenic Shock
STEMI (ST-elevation MI)
• Immediate transfer to a PCI-capable hospital (Class I,B).
• Primary PCI is recommended irrespective of symptom duration if cardiogenic shock or ongoing ischemia is present (Class I, ,B)
• CABG if PCI is not feasible (Class I ,B)
• Fibrinolysis if neither PCI nor CABG is available (Class I, 😎
• Beta blockers contraindicated in shock.
• IABP: Routine use not recommended; selective use may be considered if the patient does not stabilize with drugs and no other temporary advanced MCS (Impella, TandemHeart, VA-ECMO) is available.
• In many Level 1–2 centers, IABP remains the only feasible bridge until transfer to a Level 3 hub.
• Durable LVADs are not acute rescue devices; they are for long-term MCS or bridge-to-transplant strategies.
NSTEMI (Non-ST-elevation MI)
• Less frequent association with shock compared to STEMI, but equally critical.
• Early invasive strategy with revascularization is recommended (Class I ,B).
• Beta blockers contraindicated when shock risk is present.
• IABP may be reasonable in refractory shock if other options are not available (Class IIa, C).
CCS (Chronic Coronary Syndromes)
• Cardiogenic shock in CCS is rare.
• When it occurs, it is usually due to a superimposed acute event, such as:
• New myocardial infarction (STEMI or NSTEMI).
• Mechanical complication (acute MR from papillary muscle rupture, VSD, free wall rupture).
• Severe arrhythmias or decompensation in advanced LV dysfunction.
• In such cases, patients should be managed as ACS with shock until proven otherwise.
• Urgent ECG, echocardiography, and transfer to a PCI-capable center are essential.
Key Point:
• STEMI & NSTEMI with shock → require immediate revascularization and tailored MCS support.
• CCS with shock → almost always reflects an acute transition to ACS or a complication, so it must be managed as ACS.
4. ESC 2023 ACS Guidelines — Cardiogenic Shock
• Routine IABP not recommended (Class III)
• Short-term MCS may be considered in refractory shock (Class IIb, C).
• Priorities:
• Rapid transfer to a center with cath lab (for PCI capability).
• Immediate ECG and echocardiography.
• Continuous ECG and invasive BP monitoring.
• Coronary angiography as soon as possible (in shock: immediate, not bound to 90 minutes only).
• Fluids: only if no pulmonary congestion.
• Dobutamine: for low cardiac output when SBP ≥85–90 mmHg.
• Norepinephrine: preferred vasopressor if SBP <85 mmHg or persistent hypoperfusion.
• Dopamine discouraged due to risk of arrhythmias.
5.MCS Expert Consensus (SCAI/ACC/HFSA/STS 2015)
• IABP and ECMO were historical first-line devices.
• Impella and TandemHeart provide stronger hemodynamic support than IABP.
• Early MCS placement should be considered if no improvement with initial drugs.
• VA-ECMO supports both circulation and oxygenation; useful when shock + respiratory failure coexist.
• Right ventricular shock may need targeted RV support.
6. ISHLT (International Society for Heart and Lung Transplantation) 2024 — Long-Term Mechanical Circulatory Support (MCS) Guidance:
• Durable LVAD indicated if:
• Ventricular function unrecoverable.
• Failure to wean from temporary MCS/inotropes.
• End-organ recovery possible.
• No irreversible organ damage.
7. Pharmacologic Management
• Vasopressors: norepinephrine is first-line; avoid dopamine.
• Inotropes: dobutamine or milrinone if low cardiac output.
• Vasodilators: IV nitroglycerin (avoid in hypotension).
• Antiplatelets: aspirin early in ACS/shock.
• Analgesia: morphine reduces pain and sympathetic stress.
• Diuretics: furosemide if pulmonary congestion present.
• Other: nesiritide possible but hypotension risk limits use.
Key Takeaway :
• Levels of Care (1–3, AHA): Level 3 centers provide the highest, most comprehensive therapy including LVAD and transplant.
• Early revascularization (PCI/CABG) remains cornerstone therapy.
• Norepinephrine is the preferred vasopressor; dopamine discouraged.
• Routine IABP no longer recommended; use modern MCS (Impella, ECMO) early if shock persists.
• Focus on end-organ perfusion, not just blood pressure.
• Multidisciplinary shock teams and systematic transfer to higher levels are essential for survival.
