Cardiogenic Shock Guidelines

Updated: Jan 11, 2017
  • Author: Xiushui (Mike) Ren, MD; Chief Editor: Henry H Ooi, MD, MRCPI  more...
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Guidelines

Guidelines Summary

The following organizations have released guidelines that include recommendations for the management of cardiogenic shock:

  • American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)
  • European Society of Cardiology (ESC)

According to the 2013 ACCF/AHA guidelines for the management of ST-elevation myocardial infarction (STEMI), the greater the number of the following risk factors present, the higher the risk of developing cardiogenic shock [21] :

  • Age >70 years 
  • Systolic blood pressure (BP) <120 mm Hg
  • Sinus tachycardia =110 bpm or heart rate (HR) <60 bpm
  • Increased time since onset of symptoms of STEMI

ST-elevation myocardial infarction

The 2013 ACCF/AHA guidelines for the management patients with STEMI who develop cardiogenic shock include the following [21] :

  • Immediate transfer to a percutaneous coronary intervention (PCI)-capable hospital for coronary angiography for suitable patients (class I; level of evidence, B) 
  • Primary PCI should be performed, irrespective of time delay from the onset of myocardial infarction (MI) (class I; level of evidence, B) 
  • Urgent coronary artery bypass grafting (CABG) is indicated in patients with coronary anatomy not amenable to PCI (class I; level of evidence, B)  
  • Fibrinolytic therapy should be administered to patients who are unsuitable candidates for either PCI or CABG (class I; level of evidence, B) 
  • Beta blockers are contraindicated (class I; level of evidence, B) 
  • Intra-aortic balloon pump (IABP) counterpulsation can be useful for patients who do not quickly stabilize with pharmacologic therapy (class IIa; level of evidence, B)
  • Alternative left ventricular (LV) assist devices (LVADs) for circulatory support may be considered in patients with refractory cardiogenic shock.(class IIb; level of evidence, C)

The 2015 ESC guidelines for the management of acute coronary syndromes (ACSs) concur with ACCF/AHA guidelines for STEMI. [10]  However, the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure recommend against the routine use of IABP in the management of cardiogenic shock (class III; level of evidence, B), but short-term mechanical circulatory support (MCS) may be considered for managment of refractory cardiogenic shock in selected patients (class IIb; level of evidence, C). Additional recommendations for the management of cardiogenic shock include the following [48] :

  • Rapid transfer to a tertiary center with round-the-clock cardiac catheterization capabilities, dedicated ICU/CCU with short-term MCS (class I; level of evidence, C) 
  • Immediate electrocardiography (ECG) and echocardiography for all patients with suspected cardiogenic shock (class I; level of evidence, C) 
  • Continous ECG and blood pressure monitoring (class I; level of evidence, C) 
  • Invasive monitoring with arterial line (class I; level of evidence, C) 
  • Coronary angiography withing 2 hours of hospital admission with the intent to perform coronary revascularization for patients with cardiogenic shock complicating ACS (class I; level of evidence, C) 
  • If there is no sign of fluid overload, saline or lactated Ringer solution >200 mL/15-30 min as the first-line treatment (class I; level of evidence, C) 
  • Consider IV dobutamine to increase cardiac output (class IIb; level of evidence, C) 
  • If there is a need to maintain systolic blood pressure in the presence of persistent hypoperfusion, consider vassopressors; norepinephrine is prefered to dopamine (class IIb; level of evidence, B) 

Non–ST-elevation acute coronary syndromes

The 2014 AHA/American College of Cardiology (ACC) guideline for the management of patients with non–ST-elevation ACS (NSTE-ACS) includes the following recommendations for the management of cardiogenic shock [15] :

  • Beta blockers are contraindicated when risk factors for cardiogenic shock are present (class III)
  • Administer initial therapy with channel calcium blockers in patients with increased risk for cardiogenic shock (class I; level of evidence, B)
  • For cardiogenic shock due to cardiac pump failure, early revascularization (class I; level of evidence, B)
  • For refractory shock, IABP is reasonable (class IIa; level of evidence, C)

Mechanical circulatory support

The following organizations have released guidelines for the utilization of MCS:

  • Society for Cardiovascular Angiography and Interventions (SCAI)/ACC/Heart Failure Society of America (HFSA)/Society of Thoracic Surgeons (STS)
  • International Society of Heart and Lung Transplantation (ISHLT)

A 2015 clinical expert consensus statement from the SCAI/ACC/HFSA/STS noted that historically, the IABP and extracorporeal membrane oxygenation (ECMO) devices were the only MCS devices available to clinicians, but axial-flow pumps such as Impella and left atrium–to–femoral artery bypass pumps such as the TandemHeart subsequently entered clinical practice. The consensus-based recommendations included the following [49] :

  • Percutaneous circulatory assist devices provide superior hemodynamic support compared with pharmacologic therapy; this is particularly apparent for the Impella and Tandem-Heart devices
  • In those with cardiogenic shock who fail to stabilize or show signs of improvement after initial interventions, early placement of an appropriate MCS may be considered
  • For cardiogenic shock, IABP is less likely to provide benefit than continuous-flow pumps, including the Impella CP and TandemHeart
  • ECMO may also provide benefit, particularly for patients with impaired respiratory gas exchange
  • MCS may be considered for isolated acute right ventricular failure complicated by cardiogenic shock

In its 2013 guidelines for mechanical circulatory support, the ISHLT recommended long-term MCS for acute cardiogenic shock in the following groups (class IIa; level of evidence, C) [50] :

  • Patients whose ventricular function is deemed unrecoverable or unlikely to recover without long-term device support.
  • Patients who are deemed too ill to maintain normal hemodynamics and vital organ function with temporary MCS, or who cannot be weaned from temporary MCS or inotropic support.
  • Patients with the capacity for meaningful recovery of end-organ function and quality of life.
  • Patients without irreversible end-organ damage