The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review

Abstract

Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output (CO) leading to tissue hypoperfusion and multi-system organ dysfunction and carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and select appropriate monitoring and treatment paradigms is essential in modern intensive care units. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be best performed by multi-disciplinary shock-focused teams. In this article we provide a review of CS aimed to inform both the cardiology and non-cardiology trained intensivist provider. We briefly describe the etiologies, pathophysiology, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions.We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion—by enhancing contractility and minimizing afterload—and facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS is increasingly common. We discuss the most common devices currently utilized for patients with CS—phenotyping patients as left ventricular failure, right ventricular failure, or biventricular failure—and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.