Therapeutic Advances in the Management of Cardiogenic Shock

BACKGROUND: Despite the use of vasoactive therapies, invasive monitoring, revascularization, and/or mechanical circulatory support (MCS), cardiogenic shock (CS) continues to be associated with very high mortality. This narrative review aims to describe the therapeutic advances in the management of this syndrome. AREAS OF UNCERTAINTY: In clinical practice, many uncertainties about CS management remain, particularly regarding management in pre-CS phase, risk stratification algorithms, optimal ventilation mode, local CS protocols, appropriate selection and threshold for MCS initiation, or approach to MCS-related complications. Patients with CS without acute myocardial infarction (AMI) are substantially underrepresented in randomized controlled trials (RCTs), and future research, including new RCTs and high-quality observational studies, is imperiously needed. DATA SOURCES: Evidence-based information on CS is limited, as management recommendations and therapies are mostly extrapolated from large multicentric CS registries or RCTs in patients with AMI occurring at tertiary medical centers. In recent years, numerous studies have been published or are ongoing, emphasizing the unresolved issues in CS management. RESULTS: The results from the literature showcased the benefits of early revascularization of the culprit vessel in AMI-CS or use of pulmonary artery catheter for better overall monitoring. Despite almost universal administration of inotropes and vasopressors in patients with CS, they lack RCT evidence for increasing the survival rate. The same applies for temporary MCS, except for micro axial flow pumps which have been associated with lower 6-month mortality in a selected CS population. Large tertiary CS centers could develop regional or national networks through hub-and-spoke systems based on multidisciplinary teams and CS protocols. CONCLUSIONS: Although the current general approach to treating patients with CS has improved the prognosis, additional research is needed to overcome the key knowledge gaps and advance individualized CS treatment.