Overlooking Early Cardiogenic Shock Leads to Poor Outcomes

More than a quarter of patients with early-stage cardiogenic shock had to be transferred to a higher level of care, progressed to a worse stage of shock, or died, according to a study in six US hospitals. And patients’ conditions deteriorated within an average of 16 hours, the researchers found. 

Investigators reviewed medical records over a 6-year period (2017-2022) and found 500 patients who had experienced an early stage of cardiogenic shock, defined by hypotension or hypoperfusion. 

“These patients are thought to be typically not nearly as sick as those patients with classically manifested cardiogenic shock,” said Saraschandra Vallabhajosyula, MD, MSc, a cardiologist at the Warren Alpert Medical School of Brown University in Providence, Road Island. The study was conducted in hospitals in Rhode Island and Massachusetts in the university network. 

Catching a Killer

Shashank Sinha, MD, a cardiologist at the Inova Fairfax Medical Campus in Virginia and an author of current clinical guidance on cardiogenic shock, who was not involved in the study, said the study highlights that “beginning” or “early” shock must be identified right away.

“We are increasingly recognizing that it’s bad. There can be significant deterioration to a higher stage, with worsening mortality,” Sinha said, calling the study “a call to action.”

Of the 26% of patients with early-stage cardiogenic shock, 49% were transferred to a higher level of care, 62% had worsening shock, and 41% died in the hospital.

Early-stage cardiogenic shock was recognized in only 24% of the patients affected, Vallabhajosyula said, mainly in those whose condition deteriorated.

The study’s finding that cardiogenic shock progressed within less than a day shows the dynamic nature of shock, which can improve or worsen rapidly, Sinha said.

When a patient’s early-stage shock goes unrecognized and then worsens, care and costs are affected. “Those with poor outcomes often lingered” in the hospital for long periods, Vallabhajosyula said.

The study also found low rates of right heart catheterization (8.6%), coronary angiography (7%), and percutaneous coronary intervention (3.5%), which are often used to prevent shock from worsening. 

“That’s a potential opportunity,” Sinha said. “We certainly don’t want to provide more invasive interventions, whether it’s for monitoring or therapeutic interventions, if they don’t need them, but a percentage would benefit from them.” For example, he said, it’s important to consider right heart catheterization early in the course of cardiogenic shock. 

The study analyzed factors that predicted poor outcomes. The strongest predictor was diuretic resistance over the previous 24 hours. Acute kidney and liver injury were also common problems leading to poor outcomes, said Vallabhajosyula, especially higher stages of acute kidney injury.

Classification of Shock Changing

The study considered patients with either hypotension or hypoperfusion due to cardiac causes. According to the Society of Cardiovascular Angiography and Interventions (SCAI) current classification of cardiogenic shock as stages A (at risk) through E (extremis), hypotension alone is SCAI stage B, and hypoperfusion would be considered stage C, Sinha said. 

But he said both indicators are important in early recognition of cardiogenic shock. 

The classification system is now being fully revised, he said, and the criteria for stages could soon change.

Identifying shock in hospitals needs to improve, Vallabhajosyula and Sinha agreed.

Better surveillance of patients is key, said Vallabhajosyula, “and not just in the intensive care unit, but out in the wards,” he said, since shock may be seen in many hospital departments. 

“Other specialties need to be well-versed and have a low index of suspicion for this [shock], and not just say, ‘I’ve seen two low blood pressures, I’ll just see how the patient does,’” Sinha said. 

Education is needed among all clinicians and nurses, Vallabhajosyula said. 

“The only parameter that is checked frequently without a reason is blood pressure,” Vallabhajosyula said. Other tests that could identify shock are done less often, such as liver function tests, performed only once daily, and lactate levels, often conducted only once, he noted.

While many tests should be conducted more frequently, over testing can use precious resources for little value, he said. Electronic medical records could be used to generate alerts when a patient is at risk of cardiogenic shock, “developing clinical decision supports so that they [patients] get the right tests and the right diagnostics, regardless of who is caring for them.”

Sinha agreed with clinical decision support for cardiogenic shock. “I think we have a lot to learn from our colleagues in critical care who developed a sepsis alert more than a decade ago,” Sinha said. “How exactly we would embed this into an electronic health care record — adopt, implement, disseminate and employ it in clinical practice — have to be determined.” 

The study provides evidence that such measures are needed, he said. “It’s precisely this type of data that will help prompt this change in clinical management.” 

The findings were presented May 1 at the 2025 Scientific Sessions of the Society for Cardiovascular Angiography and Interventions. 

Sinha and Vallabhajosyula reported no relevant financial conflicts of interest 

Carolyn Brown is a freelance scientific and biomedical reporter in Ottawa, Canada.