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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e967 CLINICAL STATEMENTS AND GUIDELINES sample size, the inherent open-label study design, short follow-up, and surrogate endpoints. Recommendation-Specific Supportive Text 1. Intravenous inotropic support can increase cardiac output and improve hemodynamics in patients presenting with cardiogenic shock. Despite their ubiquitous use for initial management of cardiogenic shock, there are few prospective data and a paucity of randomized trials to guide their use.1–8 However, their broad availability, ease of administration, and clinician familiarity favor such agents as the first therapeutic consideration when signs of organ hypoperfusion persist despite empiric volume replacement and vasopressors. There is a lack of robust evidence to suggest the clear benefit of one inotropic agent over another in cardiogenic shock.30 In general, the choice of a specific inotropic agent is guided by blood pressure, concurrent arrhythmias, and availability of drug. 2. Despite the lack of direct comparative data, the use of short-term MCS has dramatically increased.9–16,31,32 The hemodynamic benefits of the specific devices vary, and few head-to-head randomized comparisons exist.33–39 Randomized clinical trials are underway that will address the risks and benefits of one modality over another. Vascular, bleeding, and neurologic complications are common to MCS devices, and the risk of such complications should generally be considered in the calculation to proceed with such support.40 As much as possible, an understanding of a patient’s wishes, overall prognosis and trajectory, and assessment of therapeutic risk should precede the use of invasive temporary MCS. 3. Team-based cardiogenic shock management provides the opportunity for various clinicians to provide their perspective and input to the patient’s management.17–22 The escalation of either pharmacological and mechanical therapies should be considered in the context of multidisciplinary teams of HF and critical care specialists, interventional cardiologists, and cardiac surgeons. Such teams should also be capable of providing appropriate palliative care. Most documented experiences have suggested outcomes improve after shock teams are instituted.17–22 In 1 such experience, the use of a shock team was associated with improved 30-day all-cause mortality (HR, 0.61; 95% CI, 0.41–0.93) and reduced inhospital mortality (61.0% vs. 47.9%; P=0.041).19 4. If time allows, escalation to MCS should be guided by invasively obtained hemodynamic data (eg, PA catheterization). Several observational experiences have associated PA catheterization use with improved outcomes, particularly in conjunction with short-term MCS.23–27,41 PA catheterization may also be useful when there is diagnostic uncertainty as to the cause of hypotension or end-organ dysfunction, particularly when a patient in shock is not responding to empiric initial shock measures.42 5. Transfer to centers capable of providing such support should be considered early in the assessment of a patient with cardiogenic shock and a trajectory of worsening end-organ malperfusion.17–22,43 The treatment of shock should be recognized as a temporizing strategy to support end-organ perfusion and blood pressure until the cause of the cardiac failure has either been treated (eg, revascularization in ST-elevation MI) or recovery (eg, myocarditis) or a definitive solution to the cardiac failure can be accomplished (eg, durable LVAD or transplant). In many cases, pharmacological or MCS can provide sufficient time to address the appropriateness of more definitive therapies (eg, bridge-to-decision) with the patient, family, and the multidisciplinary shock team. 9.6 Integration of Care: Transitions and Team-Based Approaches Recommendations for Integration of Care: Transitions and Team-Based Approaches Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 B-R 1. In patients with high-risk HF, particularly those with recurrent hospitalizations for HFrEF, referral to multidisciplinary HF disease management programs is recommended to reduce the risk of hospitalization.1–4 1 B-NR 2. In patients hospitalized with worsening HF, patient-centered discharge instructions with a clear plan for transitional care should be provided before hospital discharge.5,6 2a B-NR 3. In patients hospitalized with worsening HF, participation in systems that allow benchmarking to performance measures is reasonable to increase use of evidence-based therapy, and to improve quality of care.7–10 2a B-NR 4. In patients being discharged after hospitalization for worsening HF, an early follow-up, generally within 7 days of hospital discharge, is reasonable to optimize care and reduce rehospitalization.11,12 Synopsis For patients with HF, the transition from inpatient to outpatient care can be an especially vulnerable period because of the progressive nature of the disease state, complex medical regimens, the large number of comorbid conditions, and the multiple clinicians who may be Downloaded from http://ahajournals.org by on October 7, 2026