Guideline sources 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 2 3 Guidelines 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. C 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. B Show 2 more 2. Medical management https://web.pathway.md/diseases/recVC15cIJdXzQqC6 1/4 6/29/23, 3:44 AM Cardiogenic shock Pathway General principles: consider managing patients with cardiogenic shock by a multidisciplinary team experienced in shock. C Inotropes: administer IV inotropic support to maintain systemic perfusion and preserve end-organ performance in patients with cardiogenic shock. B Vasopressors: consider administering a vasopressor, preferably norepinephrine, to increase BP and vital organ perfusion in patients with cardiogenic shock. C Fibrinolytic therapy: administer fibrinolytic therapy, in the absence of contraindications, in patients with STEMI and cardiogenic shock unsuitable for either PCI or CABG. B 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. C 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. C 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. C Mechanical circulatory support (ACCF): consider performing placement of alternative LV assist devices for circulatory support in patients with refractory cardiogenic shock. C 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. C Do not perform intra-aortic balloon pump therapy routinely in patients with post-myocardial infarction cardiogenic shock. D 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. C Coronary 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. B Show 3 more https://web.pathway.md/diseases/recVC15cIJdXzQqC6 2/4 6/29/23, 3:44 AM Cardiogenic shock Pathway Clinical findings Symptoms Past medical history Dizziness Cardiac tamponade Dyspnea Cardiomyopathy Low urine output Coronary artery disease Orthopnea Coronary artery dissection HF Vital signs Infective endocarditis Myocardial infarction Hypotension Myocarditis Tachycardia PE Neurological exam Vascular exam Altered mental status Cold extremities Integument exam Narrow pulse pressure Cyanosis Cardiac exam Displaced apical impulse Fourth heart sound MR murmur Pulsus paradoxus Third heart sound Lab findings Lactic acidosis blood B-type natriuretic peptide Studies 2021 DOREMI In adult patients with cardiogenic shock, milrinone was not superior to dobutamine with respect to a in-hospital death from any cause, resuscitated cardiac arrest, receipt of a cardiac transplant or mechanical circulatory support, nonfatal myocardial infarction, TIA or stroke diagnosed by a neurologist, or initiation of RRT. Rebecca Mathew et al. N Engl J Med. 2021 Aug 5. 2018 CULPRIT-SHOCK (1 year follow-up) https://web.pathway.md/diseases/recVC15cIJdXzQqC6 3/4 6/29/23, 3:44 AM Cardiogenic shock Pathway In patients who had acute myocardial infarction that was complicated by cardiogenic shock, culprit- lesion-only PCI was not superior to multivessel PCI with respect to death at 1 year follow-up. Holger Thiele et al. N Engl J Med. 2018 Nov 1. Show 3 more References 1. O'Gara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61 4):e78 140. Open 2. Paul A Heidenreich, Biykem Bozkurt, David Aguilar et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Apr 1;101161CIR0000000000001063. Open 3. Theresa A McDonagh, Marco Metra, Marianna Adamo et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42 36 3599 3726. Open 4. Holger Thiele, Ibrahim Akin, Marcus Sandri et al. One-Year Outcomes after PCI Strategies in Cardiogenic Shock. N Engl J Med. 2018 Nov 1;379 18 1699 1710. Open 5. Holger Thiele, Uwe Zeymer, Franz-Josef Neumann et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock IABP SHOCK II final 12 month results of a randomised, open-label trial. Lancet. 2013 Nov 16;382 9905 1638 45. Open 6. Rebecca Mathew, Pietro Di Santo, Richard G Jung et al. Milrinone versus Dobutamine in Critically Ill Patients. N Engl J Med. 2021 Aug 5;385 6 516 525. Open 7. Rebecca Mathew, Pietro Di Santo, Richard G Jung et al. Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock. N Engl J Med. 2021 Aug 5;385 6 516 525. Open https://web.pathway.md/diseases/recVC15cIJdXzQqC6 4/4