Cardiogenic Shock — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] SCAI stage / hypoperfusion present?
   SCAI stage / is there already hypoperfusion? (Cardiac dysfunction → low output → end-organ hypoperfusion (AMI causes ~80%, mostly STEMI). Diagnosis: hypotension (SBP ≤90 for ≥30 min or vasopressors needed to keep >90) + hypoperfusion (cold extremities/altered mentation/oliguria/lactate ≥2); 'normotensive shock' exists (hypoperfusion without hypotension, higher risk). SCAI: A at-risk / B beginning (hypotension without hypoperfusion) / C classic (hypoperfusion ± 1 drug or device) / D deteriorating / E extremis (incl. arrest).)
   • C–E: hypoperfusion / shock present → SCAI C–E → revascularization + support
   • A–B: at-risk / beginning → SCAI A–B · monitor & find cause
2. [End] SCAI A–B · monitor & find cause
   SCAI A–B (at-risk/beginning, hypotension without hypoperfusion): monitor, find the cause (urgent ECG/troponin/echo), optimize volume and afterload; serial lactate/perfusion, watch for progression to stage C and escalate. In AMI, assess revascularization promptly.
3. [End] SCAI C–E → revascularization + support
   SCAI C–E (shock): find and treat the cause — emergency revascularization (primary PCI of the culprit) is the cornerstone of AMI-CS; echo to exclude mechanical complications. Hemodynamic support: norepinephrine as the first-line vasopressor, add dobutamine/milrinone as inotrope; congestion → IV loop diuretic ± ultrafiltration. Deteriorating/refractory → mechanical circulatory support (IABP/Impella/VA-ECMO). CICU/ICU, monitor lactate and perfusion, pulmonary artery catheter to phenotype if needed.

Source guidelines & references

• SCAI cardiogenic shock classification (2019/update); 2025 ACC expert consensus

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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