Guidelines adherence in the management of cardiogenic shock

Cardiogenic shock (CS) is a complex and heterogenous syndrome, representing one of the main causes of admission to intensive cardiac care units (ICCU) and remaining associated with unacceptably high morbidity and mortality. Robust high-quality evidence is missing and management strategies are often variably aligned with contemporary recommendations.

We investigated management strategies in consecutive patients admitted with CS to our level II ICCU over a six-month period (March-August 2025), in order to evaluate best practices adherence. CS was defined and categorized according the Shock Academic Research Consortium (SHARC) criteria, and severity was staged using the Society for Cardiovascular Angiography and Intervention (SCAI) classification. Clinical management, haemodynamic monitoring, and therapeutic interventions during the first 24 hours from admission were systematically assessed, with particular attention to adherence to guideline-recommended practices.

Twenty-two consecutive patients were included. The leading cause of CS was acute coronary syndrome (68.2%), followed by acutely decompensated heart failure (18.2%), secondary CS (9.1%) and de novo heart failure (4.5%). Most patients (95.5%) presented with predominant left ventricular dysfunction; two developed CS after cardiac arrest and one during a cardiac procedure. Severity stratification showed 39.1% in SCAI stage C, 43.5% in stage D and 17.4% in stage E. Management decisions, including catecholamine titration and escalation or de-escalation of MCS were guided by mean arterial pressure, echocardiographic findings, and lactate trends. Combination therapy with vasopressor and inotrope was the most frequent initial strategy (73.7%), while inotrope monotherapy was less common. Norepinephrine was the preferred vasopressor (68.4%), and dobutamine was the most commonly used inotrope (42.1%). Seventeen patients were referred to the cath-lab. Intra-aortic balloon pump use was infrequent (18.1%), and no other MCS devices were deployed. Invasive arterial pressure monitoring was universally applied, but no patients received pulmonary artery catheterization. A dedicated shock team was involved in 45.4% of cases, and no patients were transferred to a higher-level shock center.

The management of CS in a level II ICCU remains heterogeneous and only partially aligned with current recommendations. Important gaps include limited use of structured shock teams, lack of escalation to advanced MCS devices, and absence of early referral pathways to specialized centers. These findings underscore the need for systematic implementation of interdisciplinary shock teams, standardization of early management protocols, and routine case reviews as part of continuous quality improvement initiatives. Building structured pathways and promoting collaborative care networks will be critical to improving outcomes in this high-risk population.