Definitions of Cardiogenic Shock and Indications for Temporary Mechanical Circulatory Support: Joint Consensus Report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society.

Abstract

Background: The management of patients with cardiogenic shock (CS) is complex and resource-intensive, particularly given the recent surge in temporary mechanical circulatory support (tMCS) devices. This document was created to establish an approach to the assessment of CS to provide early and targeted therapies, including tMCS.

Methods: An interdisciplinary, international panel of experts, utilizing a structured appraisal of the literature and a modified Delphi method, derived consensus regarding the assessment of CS based on pathophysiologic severity, etiology, and phenotypic clustering to guide escalation of care as well as identify those patients who might benefit from tMCS.

Results: Key principles included early and continuous assessment for the evolution of shock severity to guide the escalation of care as well as establishment of the cause of CS to facilitate triage and assignment of initial therapies. Phenotypic clustering is complementary and aids in prognosis. tMCS provides the greatest benefit in CS for relief of congestion refractory to medical therapy, ideally when initiated before the development of organ injury. The use of tMCS should be preceded by an interdisciplinary discussion as part of the informed consent process to establish therapeutic goals, including exit strategies.

Conclusions: Based on the available literature and expert consensus, there is an opportunity to further standardize the approach to CS, including characterization based on the severity of the shock state, etiology, and further enhancement by phenotyping. Monitoring, early triage and timely escalation of care, including the targeted initiation of tMCS, can minimize organ injury and in-hospital mortality.