ACC Releases ‘Concise Clinical Guidance’ for Cardiogenic Shock Care

In an effort to encourage best practices for cardiogenic shock care, the American College of Cardiology (ACC) has issued a consensus statement that provides practical advice to inform evaluation and management.

The document, published Monday in the Journal of the American College of Cardiology, is the professional society’s first ever Concise Clinical Guidance, a format meant to aid clinicians when the evidence required for more-formal expert consensus decision pathways or guideline recommendations isn’t yet available.

Writing group chair Shashank S. Sinha, MD (Inova Fairfax Medical Campus, VA), told TCTMD that members of the ACC’s Critical Care Cardiology section had proposed the topic of cardiogenic shock for inclusion in the new series. This is an area where randomized data have “really been lacking,” with just one positive trial—the DanGer Shock study of STEMI patients—over the past three decades, he said.

Cardiogenic shock, a “complex, heterogeneous, multifactorial syndrome,” is notoriously challenging, the authors note. Short-term mortality is in the range of 30-40%, and 1-year mortality is around 50% or higher. “That’s quite frankly abysmal, and we need to get better,” Sinha stressed.

While DanGer Shock’s results have sparked discussions on next directions, they only apply to around 5% of the entire shock population. Sinha pointed out that the new guidance covers both heart failure and acute MI.

In this “data-scarce zone,” registries have helped shed light on best practices, said Sinha, who added that their document, designed for the community clinician, had input from “experts across disciplines and specialties who grapple with these questions every day.” Importantly, these are not formal guideline recommendations, he specified.

Saraschandra Vallabhajosyula, MD (Brown University, Providence, RI), providing outside perspective on the new paper, commented to TCTMD: “It’s very well thought out, clearly by a well-respected group of experts, and well written. I think it has a lot of good, important information.” It will be particularly useful, he said, “for smaller centers that would like to improve their shock outcomes.”

Also speaking with TCTMD about the guidance, Claudius Mahr, DO (Medical City Healthcare, Dallas, TX), said “it codifies what people who are thought leaders in this space have been preaching for quite some time.” Valuably, by bringing this topic to the forefront, “it gives us ammunition and a tool to essentially try to move the more change-resistant entities along the right path,” said Mahr.

The advice, he continued, can be summed up as: “Do the right thing, identify the patient, triage them appropriately, escalate them to a higher level of care, if appropriate, in a timely fashion.”

While this paper offers “a blueprint of what that looks like,” said Mahr, “ultimately, there are going to have to be key performance metrics, like the door-to-balloon time in ST-elevation MI, to say: how does your hospital and your health system perform compared to the broader cardiogenic shock space?”

Right now, “there’s quite a bit of practice variation,” which in turns leads to wide variation in shock survival rates across hospitals, he added.

Obviously, we’re trying to get the patient to survive, but really our long-term goal here is to help them thrive. Shashank S. Sinha

The guidance covers the initial evaluation of cardiogenic shock, transfer of patients with the condition, activation of the cardiogenic shock team, and use of invasive hemodynamics. It also includes advice on mechanical circulatory support, pharmacological therapies, and critical care management.

Given the complexity of cardiogenic shock, dealing with it is truly a “team-based sport,” said Sinha. In the inpatient setting, “obviously, we’re trying to get the patient to survive, but really our long-term goal here is to help them thrive.”

Sinha pointed to several key takeaways. Use of SCAI SHOCK staging, for example, can aid communication across centers and allow for consistency in research studies. Early recognition is critical as well, ideally with invasive hemodynamics—an approach currently being tested in the PACCS randomized trial. With shock, it’s important to “reassess, reassess, reassess,” he said, emphasizing the need for “serial engagement to note the trajectory of shock, particularly in those first 6 to 24 hours.”

To this end, the guidance provides a “road map” outlining specific steps for clinicians to take in the early hours of cardiogenic shock.

Room for Growth

Vallabhajosyula pointed out two areas he believes deserve to be fleshed out.

For one thing, the document emphasizes “shock teams,” whereas he made an argument for “shock protocols,” since not all hospitals have the resources for a dedicated team but all can come up with processes that optimize care. “You cannot expect every center to have a team of four or five dedicated physicians who treat shock with a lot of interest and enthusiasm,” Vallabhajosyula said. “What you really need are the agreed upon principles of best practices for these patients that can then be propagated across the healthcare system and network” with a specific plan in place for when to contact that region’s hub hospital.

The “triggers for transfer” also aren’t clearly delineated in the guidance, in part because there’s little consensus on what should guide the decision to send a patient to a cardiogenic shock center, he said. “We are using too many subjective criteria.”

The ACC document specifies that patients with acute MI who remain in refractory cardiogenic shock even after revascularization “should almost always” be sent to a level 1 center. Additionally, “patients who have experienced a cardiac arrest with tenuous neurological status, or patients who have been initiated on ≥ 1 vasoactive medication, or those in whom a temporary mechanical circulatory device is being considered, should also prompt communication with the cardiogenic shock regional center to determine whether, and when, transfer should be pursued,” it suggests.

Vallabhajosyula said there remains some ambiguity even with that guidance, noting that not all vasopressors are the same: there are different types given at different doses. This leaves open questions around the right time for transfer. A better approach would be to consider objective measures that capture cumulative vasopressor use, he said, citing a 2024 paper he co-authored on the subject in Mayo Clinic Proceedings.

For Mahr, one upside to the document is that it establishes what constitutes a level 1 cardiogenic shock center, with expertise in all aspects of shock care, versus level 2 (STEMI and/or PCI capabilities with the option of mechanical circulatory support) and level 3 (capable of diagnosing cardiogenic shock) centers. This perspective on transfer, paired with the road map’s timelines, “actually gives a fair bit of structure around what this would look like,” he said.

Looking forward, Sinha said, complications in the care of cardiogenic shock merit close attention. Indeed, the “prevention, recognition, and management of complications is really the next frontier” in research and practice, he said. “That’s where we really, as a community, need to get better in training all providers who are frontline clinicians in managing this devastating condition.”

Sinha highlighted two trials, in addition to PACCS, to keep an eye on: Altshock-2, set to be presented soon at the ACC’s 2025 meeting, as well as UNLOAD ECMO.