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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e966

CLINICAL STATEMENTS AND GUIDELINES

a critical reduction in cardiac output manifest by endorgan dysfunction.28 Hypotension (eg, SBP <90 mm Hg) is the primary clinical manifestation of shock but is not sufficient for the diagnosis. Additionally, end-organ hypoperfusion should be present as a consequence of cardiac dysfunction (Tables 22, 23, 24).29 Causes can be broadly separated into acute decompensations of chronic HF, acute myocardial dysfunction without precedent HF, and survivors of cardiac arrest. In the case of acute MI, urgent revascularization is paramount. The approach to cardiogenic shock should include its early recognition, invasive hemodynamic assessment when there is insufficient clinical improvement to initial measures and providing appropriate pharmacological and MCS to optimize end-organ perfusion and prevent metabolic complications. The evidence that supports the use of specific pharmacologic therapies and the nature of temporary MCS is primarily gleaned from observational retrospective datasets. Only a few randomized trials have been conducted to assess the most appropriate circulatory support device, and they have been limited by small

Table 22.  Suggested Shock Clinical Criteria*29 SBP <90 mm Hg for >30 min: a.  Or mean BP <60 mm Hg for >30 min b.  Or requirement of vasopressors to maintain systolic BP ≥90 mm Hg or

mean BP ≥60 mm Hg Hypoperfusion defined by: c.  Decreased mentation d.  Cold extremities, livedo reticularis e.  Urine output <30 mL/h f.  Lactate >2 mmol/L BP indicates blood pressure; and SBP, systolic blood pressure. *Systolic BP and hypoperfusion criteria need to be met for the shock diagnosis. Table 23.  Suggested Shock Hemodynamic Criteria*29

1 SBP <90 mm Hg or mean BP <60 mm Hg

2.	 Cardiac index <2.2 L/min/m2

3 Pulmonary capillary wedge pressure >15 mm Hg

4.	 Other hemodynamic considerations a.  Cardiac power output ([CO x MAP]/451) <0.6 W b.  Shock index (HR/systolic BP) >1.0 c.  RV shock

i.  Pulmonary artery pulse index [(PASP-PADP)/CVP] <1.0 ii.  CVP >15 mm Hg iii.  CVP-PCW >0.6 BP indicates blood pressure; CO, cardiac output; CVP, central venous pressure; HR, heart rate; MAP, mean arterial pressure; PADP, pulmonary artery diastolic pressure; PASP, pulmonary artery systolic pressure; PCW, pulmonary capillary wedge; RV, right ventricular; and SBP, systolic blood pressure. *Diagnosis of shock requires ≥1 criteria to be present along with cardiac index <2.0 L/min/m2 and SBP <90 mm Hg.

Table 24.  Society for Cardiovascular Angiography and Interventions (SCAI) Cardiogenic Shock Criteria29 Stage Bedside Findings Selected Laboratory Markers Hemodynamics A: At risk Normotensive Normal perfusion Cause for risk for shock such as

large myocardial infarction or HF Normal venous pressure

Clear lungs Warm extremities Strong palpable pulses Normal mentation Normal renal function

Normal lactate SBP >100 mm Hg

Hemodynamics: Normal

B: Beginning shock (“pre-shock”) Hypotension Normal perfusion Elevated venous pressure

Rales present Warm extremities Strong pulses Normal mentation Preserved renal function

Normal lactate Elevated BNP SBP <90 mm Hg, MAP <60 mm Hg, or >30 mm Hg decrease from baseline SBP

HR >100 bpm Hemodynamics: CI ≥2.2 L/min/m2

C: Classic cardiogenic shock Hypotension Hypoperfusion Elevated venous pressure

Rales present Cold, ashen, livedo Weak or nonpalpable pulses Altered mentation Decreased urine output Respiratory distress Impaired renal function

Increased lactate Elevated BNP Increased LFTs Acidosis SBP <90 mm Hg; MAP <60 mm Hg; >30 mm Hg from baseline SBP despite drugs and temporary MCS

HR >100 bpm Hemodynamics: CI ≤2.2 L/min/m2; PCW >15 mm Hg; CPO <0.6 W; PAPi <2.0; CVP-PCW >1.0

D: Deteriorating Worsening hypotension Worsening hypoperfusion Same as stage C Persistent or worsening values of stage C Escalating use of pressors or MCS to maintain SBP and end-organ perfusion in setting of stage C hemodynamics E: Extremis Refractory hypotension Refractory hypoperfusion Cardiac arrest

CPR Worsening values of stage C laboratories SBP only with resuscitation

PEA Recurrent VT/VF

BNP indicates brain natriuretic peptide; CI, cardiac index; CPO, cardiac power output; CPR, cardiopulmonary resuscitation; CVP, central venous pressure; HR, heart rate; LFT, liver function test; MAP, mean arterial blood pressure; MCS, mechanical circulatory support; PAPi, pulmonary artery pulsatility index; PCW, pulmonary capillary wedge pressures; PEA, pulseless electrical activity; SBP, systolic blood pressure; VF, ventricular fibrillation; and VT, ventricular tachycardia.

Adapted from Baran D et al,29 with permission from Wiley Periodicals, Inc.

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