AHA scientific statement on the contemporary management of cardiogenic shock

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes.

Cardiogenic shock (CS) is a low-cardiac-output state resulting in life-threatening end-organ hypoperfusion and hypoxia. Acute myocardial infarction (MI) with left ventricular (LV) dysfunction remains the most frequent cause of Cardiogenic shock.Before the routine use of early revascularization, MI associated had an in-hospital mortality exceeding 80%.Treatment efforts to reduce mortality initially focused on improvement of hemodynamic parameters by mechanical devices like intra-aortic balloon pump (IABP).

The first major breakthrough in CS treatment was achieved by the randomized SHOCK trial. Although an early invasive strategy coupled with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) did not reduce 30-day mortality (the primary
outcome of the trial), a significant mortality reduction emerged at 6 and 12 months that persisted at longer-term follow-up. Subsequent registries confirmed the survival advantage of early revascularization.Further efforts to reduce CS mortality have been directed toward improvements in MCS devices.

CS is a multifactorial and hemodynamically diverse high acuity illness that is frequently associated with multisystem organ failure. The complexity of CS requires a widespread application of best-care practice standards and a coordinated regionalized approach to CS with multidisciplinary care in designated tertiary care centers that have the expertise, clinical volume, and resources necessary to centralize the delivery of the medical, surgical, and mechanical therapies highlighted in this document. Despite its prevalence, few trials have been performed, and CS remains a relatively understudied cardiovascular disease state.

The pathophysiology of CS remains poorly elucidated; many routine CS therapeutic practices have not been rigorously tested, and new medical treatment options are urgently needed to reduce the significant patient morbidity and mortality associated with this condition. To address the knowledge gap, we advocate for coordinated international efforts to identify CS research priorities, to conduct clinical trials, and to create large population-based registries to generate quality improvement opportunities. These endeavors could form the basis for future scientific discovery, guideline development, and improved patient outcomes.

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http://circ.ahajournals.org/content/early/2017/09/18/cir.0000000000000525