Experts’ recommendations for the management of adult patients with cardiogenic shock - 01/04/26

Doi : 10.1016/j.aicoj.2026.100038

Nadia Aissaoui ^a,^{^{1
The authors contributed equally.},}⁎ , Clement Delmas ^b,^c,^{^{1
The authors contributed equally.}}, Hamid Merdji ^d, Guillaume Schurtz ^e, Guillaume Baudry ^f,^g,^h, Antoine Beurton ^i,^j, Florence Boissier ^k,^l, Laurent Bonello ^m, Bernard Cholley ^n,^o, Nicolas Combaret ^f,^g,^h, Alain Combes ^p, Charles-Henri David ^q, Daniel De Backer ^r, Pierre Grégoire Guinot ^s, Olfa Hamzaoui ^t, Brahim Harbaoui ^u,^v, Julien Imbault ^i,^j, Nicolas Nesseler ^w, Antoine Kimmoun ^x, Michel Kindo ^y, Guillaume Lebreton ^z, Guillaume Leurent ^aa, Bruno Levy ^ab, Stéphane Manzo-Silberman ^ac,^ad, Anne-Céline Martin ^ae,^af, Armand Mekontso-Dessap ^ag,^ah, Imane Adda ^ai, Joy Mootien ^aj, Alexandre Ouattara ^ak, Matteo Pozzi ^al, Etienne Puymirat ^am,^an, Francois Roubille ^ao, Antonin Trimaille ^ap, Aurore Ughetto ^aq, Eric Van Belle ^e, Eric Bonnefoy ^ar, Khaldoun Kuteifan ^as

^a Intensive Cardiac Care Unit, Cardiology Department, Hopital Européen Georges Pompidou, Assistance Publqiue des Hopitaux de Paris, Université Paris Cité, Paris, France

^b Intensive Cardiac Care Unit, Cardiology Department, Toulouse University Hospital, Toulouse University, INSERM, UMR 1297, Institut des Maladies Métaboliques et Cardiovasculaires - I2MC, Toulouse, France

^c REICATRA, Institu Saint Jacques, Toulouse, France

^d Department of Medical Intensive Care, University Hospital of Strasbourg, Nouvel Hôpital Civil, INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France

^e Cardiac Intensive Care Unit, Insitut Coeur Poumon, CHU Lille, Lille, France

^f Université de Lorraine, INSERM, Centre d'Investigation Clinique Plurithématique 1433, Inserm U1116, CHRU de Nancy, Nancy, France

^g INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France

^h REICATRA, France

ⁱ CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, CHU de Bordeaux, F-33000 Bordeaux, France

^j Univ. Bordeaux, INSERM, BMC, U1034, F-33600 Pessac, France

^k CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France

^l INSERM, Centre d’Investigation Clinique CIC 14-02 IS-ALIVE, Université de Poitiers, F-86000 Poitiers, France

^m Unite de Soins Intensifs de Cardiologie, Hopital Nord de Marseille, Aix-Marseille Université, Marseille 13015 France

ⁿ Service d’Anesthésie-Réanimation & Médecine Péri-Opératoire, Hôpital Européen Georges Pompidou, APHP, Paris, France

^o INSERM UMR-S1140, Université Paris Cité, Paris, France

^p Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, AP-HP, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hopital Pitié Salpêtrière, Paris, France

^q Nantes Université, CHU Nantes, Chirurgie Thoracique et Cardiovasculaire, l'Institut du Thorax, F-44000 Nantes, France

^r Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium

^s Department of Anesthesiology and Intensive Care, Dijon University Hospital, University of Burgundy Europe, LNC UMR1231, F-21000 Dijon, France

^t CHU Reims, Unité de Médecine Intensive et Réanimation Polyvalente, Université de Reims Champagne-Ardenne, UR 3801 PPF, Reims, France

^u Interventional Cardiology Department, Hôpital Croix-Rousse, and Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France

^v University of Lyon, CREATIS UMR5220, INSERM U1044, INSA-15 Lyon, France

^w Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d’Investigation Clinique de Rennes), Inrae, Institut NUMECAN – UMR_A 1341, UMR_S 1241, FHU SUPORT, F-35000 Rennes, France

^x Université de Lorraine, CHRU de Nancy, Service de Médecine Intensive et Réanimation Brabois, U1116, F-CRIN INI CRCT, Nancy, France

^y Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France

^z Sorbonne Université, AP-HP, Service de Chrirugie Cardiaque, Institut de Cardiologie, Hopital Pitié Salpêtrière, Paris, France

^aa Department of Cardiology, Univ Rennes 1, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France

^ab Institut du Coeur et des Vaisseaux, CHU Nancy-Brabois, Groupe Choc, équipe 2, Inserm U1116. Faculté de Médecine, Nancy, France

^ac AP-HP, Cardiology Department, Cardiology Institut, Hôpital Pitié Salpêtrière, Paris, France

^ad Sorbonne University, INSERM, UMRS_1166-ICAN; ACTION Study Group, Paris, France

^ae Division of Cardiology, Advanced Heart Failure Unit, AP-HP, Hôpital Européen Georges-Pompidou, F-75015, Paris, France

^af Université Paris Cité, INSERM, PARCC, F-75015 Paris, France

^ag AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Univ Paris Est Créteil, INSERM, Institut Mondor, CARMAS, Créteil, F-94010, France

^ah Department of Cardiac Surgery, Louis Pradel Hospital, Lyon, France

^ai Department of Research, One Clinic, PointGyn, Paris, France

^aj Unité Fonctionnelle de Conseil en Antibiothérapie, CHU Mulhouse, Mulhouse, France

^ak 1CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, CHU de Bordeaux, Univ. Bordeaux, INSERM, BMC, U1034, France

^al Department of Cardiac Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Research on Healthcare Performance Reshape, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France

^am Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology, 75015 Paris, France

^an PARCC, Université de Paris Cité, 75006 Paris, France

^ao PhyMedExp, Cardiology Department, Université de Montpellier, INSERM, CNRS, INI-CRT, CHU de Montpellier, Montpellier, France

^ap Department of Cardiovascular Medicine Nouvel Hôpital Civil, 2UR 3074, Translational Cardiovascular Medicine Biomedicine Research Centre of Strasbourg, University of Strasbourg, Strasbourg, France

^aq Department of Cardiothoracic Anesthesia and Critical Care Medicine, Montpellier University Hospital, Montpellier, France

^ar Department of Cardiology, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INSA-Lyon, University Claude Bernard Lyon 1, Lyon, France

^as Medical Intensive Care Unit, GHRMSA, Mulhouse, France

^⁎ Corresponding author at: Departement of Cardiology, Hopital Européen Georges Pompidou, 25 rue Leblanc, 75015 Paris, France. Departement of Cardiology Hopital Européen Georges Pompidou 25 rue Leblanc Paris 75015 France

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Graphical abstract

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Abstract

The last specific international European recommendations regarding the management of cardiogenic shock (CS) regardless of the etiology were issued over 10 years ago. We present herein recommendations for the management of CS in adults, developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of from the French Intensive Care Society [Société de Réanimation de Langue Française (SRLF)] and the French Society of Cardiology [Société Française de Cardiologie (SFC)], with the participation of the French Society of Anesthesia and Intensive Care [Société Française d'Anesthésie et de Réanimation (SFAR)], and the French Society of Thoracic and Cardiovascular Surgery [Société Française de Chirurgie Thoracique et Cardio-Vasculaire (SFCTCV)].

The recommendations covered six fields of application: CS teams and expert centers, symptomatic medical management, etiological management, organ support, temporary circulatory support and de-escalation and early post-CS management. Twenty-three “Patient Intervention Comparator Outcome” (PICO) questions were identified, leading to 41 recommendations regarding management of CS in adult patients. Seven recommendations were scored with high level of evidence (Grade 1), 11 with moderate level of evidence (Grade 2) and 17 with low level of evidence (Expert opinion). In 6 cases, the experts were not able to give an answer. All of the recommendations obtained strong agreement from the expert committee.

The experts highlight the fact that optimal management of CS requires organization including a structured, multidisciplinary shock team and regional referral network, applying standardized protocols for diagnosis and staging. Early etiological treatment—such as culprit-lesion revascularization or urgent valve intervention—is central to improve outcomes. Hemodynamic support should prioritize norepinephrine as first-line vasopressor and privilege selective inotrope use. Temporary mechanical circulatory support (Impella, VA-ECMO) should be reserved for carefully selected patients following discussion by the expert team.

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Abbreviations : ACS, AS, AR, BAV, BiVAD, CABG, CS, GRADE, HF, HFNC, IABP, ICU, IMV, LVAD, MACE, m-AFP, MI, MR, M-TEER, NIV, NSTEMI, PCI, PEEP, PICO, RCT, RRT, SCAI, STEMI, SAVR, TAVR, TH, t-MCS, VA-ECMO, VO2