Skip to content

Cardiogenic Shock

Sims Hershey


  • Impairment of CO due to primary cardiac disorder that results in end-organ hypoperfusion and hypoxia
  • Mortality of up to 40-50%


  • Cardiomyopathic: myocardial infarction with LV dysfunction (most common cause), exacerbation of heart failure, PHTN exacerbation, myocarditis, myocardial contusion, drug-induced
  • Arrhythmic: atrial tachycardias (atrial fibrillation/flutter, AVRT, AVNRT), VT/VF, complete heart block, 2nd degree heart block
  • Mechanical: valvular insufficiency, valvular rupture, papillary muscle rupture, critical valvular stenosis, ventricular septal wall defect, ruptured ventricular wall aneurysm, atrial myxoma, HOCM

Presentation and diagnostic criteria

  • "Cold and wet" - decreased perfusion due to reduced cardiac output with pulmonary congestion and/or increased left sided filling pressures. May also be "cold and dry" in the setting of normal PCWP with low cardiac output.
  • Signs of end-organ hypoperfusion - AMS, cold and clammy skin, decreased UOP (\<30cc/hr), and elevated lactate (>2).
  • SBP \< 90 mmHg for >30min or needing vasopressors to achieve this goal, usually with narrow pulse pressure
  • Initially, SVR is elevated in the s/o hypoperfusion. SVR then declines in progressive shock due to vasodilation in the s/o systemic inflammation causing elevated NO in the shock state.


  • EKG
  • Labs: CBC, CMP, BNP, troponin, lactate
    • Evidence of end organ damage: lactic acidosis, acute kidney injury, acute liver injury
  • Echocardiogram: assess EF and valves
  • LHC If ischemia (see ACS)
  • Hemodynamic monitoring via Swan-Ganz or PA catheter:
    • No benefit for general shock but does improve in-hospital mortality for those with cardiogenic shock
    • PA catheter hemodynamic profile:
      • Cardiac index \< 2.2, cardiac power \<0.6, SVR 800-1600, SVO2 \<60%
      • LV-dominant: RA (CVP) \<15, PCWP >18, PAPi >1.5 (pulmonary artery pulsatility index)
      • RV-dominant: RA >15, PCWP \<18, PAPi >1.5
      • Bi-V-dominant: RA >15, PCWP >18, PAPi >1.5
      • PAPi \< 1 indicates that patient will likely need RV support
      • CP \< 0.5 strongest independent hemodynamic correlate of mortality in CS
      • See right heart cath section for interpreting PA catheter profiles

Management (medical & mechanical circulatory support)

Medical management

  • Medical management: focus on optimizing preload, afterload, and contractility
    • Preload: IV diuresis -- hypotension IMPROVES with diuresis in cardiogenic shock
    • Afterload: IV -- nitroglycerine, nitroprusside; PO -- hydralazine, isosorbide dinitrate; vasoconstricting pressors (phenylephrine, vasopressin) if needing BP support
    • Contractility - Inodilators (increase contractility, decrease afterload -- milrinone, dobutamine) or inoconstrictors (increase contractility and afterload -- epinephrine, norepinephrine)

Mechanical circulatory support indications

  • Shock refractory to >1 pressor
  • Shock 2/2 MI (physiology: unloads LV, increases systemic perfusion, increases myocardial perfusion, and provides hemodynamic support during PCI)

Types of mechanical circulatory support (MCS)

Intra-aortic Balloon Pump V-A ECMO Tandem Heart Impella
Dynamics Inflates during diastole, deflates during systole Blood from femoral vein is oxygenated and pumped to femoral artery

LV: blood aspirated from LA to femoral artery

RV: blood aspirate from RA to PA

Impella 2.5, 5.0 & CP: Blood aspirated from LV to aortic root

Impella RP: Blood aspirated from IVC and delivered to PA

Flow 1 LMP 4.5 LPM 4-5 LPM

2.5: 2.5 L/min

CP: 3.33 L/min

5.0: 5 L/min

RP: 4 L/min

Support LV BiV LV, RV, or BiV LV or RV (RP)

Reduces afterload

Increases stroke volume (SV)

Increases coronary perfusion

Reduces LV preload and PCWP

Increases afterload

Reduces SV

Reduces LV preload and PCWP

Improves tissue perfusion

Increases afterload

Reduces SV

Reduces LV preload and PCWP

Improves tissue perfusion

Reduces SV

Reduces preload and PCWP

Improves tissue perfusion




Arterial obstruction

Aortic rupture or dissection

Air embolism

Circuit thrombosis

LV dilation


Gas embolism

Tamponade d/t perforation


Embolism (gas or thrombus)

Arterial Shunt

Pump migration


Aortic regurg

LV perf


Possible contraindications to mechanical circulatory support:

  • Aortic regurgitation, intracardiac shunt via ASD, VSD, or PFO, severe RV dysfunction, LA or ventricular thrombus, aortic dissection, uncontrolled sepsis, severe coagulopathy or bleeding diathesis

Daily management of MCS devices:

  • Ensure optimal placement of device with daily CXR/Echo

  • Anticoagulation (based on device)

  • Hematoma monitoring at device site

  • Check distal pulses to monitor for limb ischemia