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Cardiogenic Shock Management (Adults, ESC 2026 + SCAI)

Cardiogenic Shock Management (Adults, ESC 2026 + SCAI): Cardiogenic Shock (Adults) → Find and Treat the Cause Now → LVOT Obstruction (Takotsubo, HCM): N...

Pathway Overview

13 steps

Algorithm Steps

13 total

  1. 01Start

    Cardiogenic Shock (Adults)

    Hypoperfusion (cold skin, confusion, oliguria, lactate >2 mmol/L) from a primary cardiac cause. Often SBP <90 mmHg, but there is no fixed BP cut-off. Exclude or treat septic and hypovolaemic shock; mixed shock can occur.

    • Most common cause: acute myocardial infarction
  2. 02Action

    Find and Treat the Cause Now

    Start at once, in parallel with circulatory support. Tamponade: drain. PE: reperfusion. Arrhythmia or severe bradycardia: cardioversion or pacing. No cath lab or MCS on site: call the shock centre and retrieval service early.

    • 12-lead ECG and emergency echo (LV, RV, LVOT, valves, pericardium)
    • ACS: immediate angiography; PCI of the culprit artery only. PCI not feasible or failed: emergency CABG
    • STEMI, primary PCI not possible within 120 min: consider fibrinolysis if no contraindication (e.g. prolonged or traumatic CPR, aortic dissection, recent bleeding or stroke) and no mechanical complication on echo; then transfer for angiography
    • Mechanical complication (VSD, papillary muscle or free-wall rupture): emergency surgical or catheter repair
  3. 03Warning

    LVOT Obstruction (Takotsubo, HCM): No Inotropes or IABP

    Check the echo for a dynamic LVOT gradient, especially with apical ballooning or septal hypertrophy. Inotropes and IABP raise the gradient and worsen shock. Takotsubo without a gradient: avoid catecholamines if possible, call the Shock Team early for MCS, and repeat the echo, as a gradient can develop.

    • Avoid dobutamine, milrinone, adrenaline, IABP, nitrates and diuretics
    • Give IV fluid if no pulmonary oedema
    • Hypotension: vasoconstrictor without inotropic effect (e.g. phenylephrine), not norepinephrine. Shock Team for beta-blocker or device
  4. 04Action

    Support the Circulation

    Stop or reduce beta-blockers and other BP-lowering heart failure drugs. Arterial line and continuous monitoring of lactate, urine output and mental state. Fluid challenge only if no congestion. RV infarction or PE: small boluses only, reassess after each. Congestion: IV loop diuretic once BP and perfusion are supported.

    • Hypotension: vasopressor, norepinephrine preferred (IIb)
    • Low output with hypoperfusion despite fluids: inotrope, e.g. dobutamine (IIb), lowest effective dose (arrhythmia, ischaemia). On a beta-blocker: milrinone may be preferred
    • Pregnant or recently delivered (possible peripartum cardiomyopathy): avoid dobutamine if possible; Shock Team early for MCS; obstetric team for urgent delivery if still pregnant
    • SpO2 <90%: oxygen. Respiratory failure: NIV or intubation; positive pressure can drop BP, most in RV failure
  5. 05Action

    SCAI Stage: Reassess Often

    Stage guides escalation

    • A At risk: no signs of shock yet. B Pre-shock: hypotension or tachycardia, no hypoperfusion
    • C Classic: hypoperfusion needing drugs or MCS
    • D Deteriorating: not responding to initial treatment
    • E Extremis: refractory shock or cardiac arrest
  6. 06Decision

    Still Hypoperfused Despite Drugs (SCAI D-E), or STEMI Shock With LV Failure?

    Call the Shock Team. STEMI shock: decide on MCS at angiography.

  7. If Yes
    1. 07Warning

      Temporary MCS: Selected Patients Only

      Shock Team chooses the device. Routine MCS in unselected MI shock is not recommended (III): more harm. HF-related shock (not MI): device as a bridge in selected patients (IIa). Devices need anticoagulation: active bleeding or recent fibrinolysis raises bleeding risk.

      • Routine IABP: no benefit (III). Use in MI mechanical complication as bridge
      • No microaxial pump: LV thrombus, mechanical aortic valve, severe AS, moderate-severe AR, VSD, severe PAD
      • LV free-wall rupture: no MCS; VA-ECMO only as bridge to surgery
    2. STEMI, LV failure
    3. 08Action

      STEMI Shock With LV Failure: Microaxial Flow Pump

      Consider (IIa) only if no risk of hypoxic brain injury. Experienced centre.

      • Hypoxic brain injury risk: OHCA with GCS <8 after ROSC, or CPR 10 min or more
      • LV support only: not for significant RV failure
      • Watch for bleeding, limb ischaemia, haemolysis, kidney injury
    4. Refractory or RV failure
    5. 09Action

      Refractory or Biventricular Failure: VA-ECMO

      Selected patients only, as a bridge to recovery, decision or transplant (Shock Team). Routine use in MI shock: no survival benefit (ECLS-SHOCK). Gives full circulatory and respiratory support.

      • Not for: severe aortic regurgitation, acute aortic dissection before repair, severe aortic or peripheral artery disease, prolonged anoxic brain injury
      • Large VSD: use with caution, left-to-right shunt can increase
      • Raises LV afterload: watch for LV distension; unload only if needed
      • Needs anticoagulation: watch for bleeding and limb ischaemia
    6. 10Decision

      Perfusion Improving?

      Lactate falling; urine output and mental state better

    7. If Yes
      1. 11Outcome

        Improving: Wean Support Stepwise

        Wean MCS and drugs. Start heart failure therapy when stable. Pregnant: no ACE-I, ARB, ARNI, MRA, ivabradine or SGLT2-I.

      If No
      1. 12Outcome

        Not Improving: Shock Team and Advanced HF Team

        Shock Team review: temporary MCS if not yet used and suitable. Then discuss durable LVAD, transplant or palliative care.

    8. Responding
    9. Path rejoins step 10Shared downstream outcome
    10. Refractory or biventricular
    11. Path rejoins step 09Shared downstream outcome
    If No
    1. No, responding
    2. 13Action

      Responding: CCU/ICU Care

      Continue treatment of the cause. Wean drugs as perfusion improves.

      • Reassess SCAI stage, lactate and urine output often
      • Hypoperfusion returns: call the Shock Team
    3. Path rejoins step 10Shared downstream outcome

Guideline Source

2026 ESC Guidelines for the management of heart failure (cardiogenic shock) with 2023 ESC Guidelines for the management of acute coronary syndromes

DOI: 10.1093/eurheartj/ehag100View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only. Not for septic, hypovolaemic or other non-cardiac shock.
  • No drug doses: use local vasoactive infusion protocols. Device choice needs a Shock Team; microaxial pumps and VA-ECMO are available only in some centres.
  • Evidence of MCS benefit is limited to selected STEMI shock (DanGer Shock); device harms are common.

Contraindicated Populations

pediatric

Applicable Regions

EUUSAU

AU: Microaxial flow pumps and VA-ECMO are available only in some tertiary centres. Call the regional cardiac surgery or ECMO centre and the retrieval service early. STEMI shock with no PCI available: consider fibrinolysis, then angiography (NHFA/CSANZ ACS guideline 2025).

EU: ESC 2026 heart failure and ESC 2023 ACS guidelines; SCAI staging.

US: SCAI classification widely adopted.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Cardiogenic Shock Management (Adults, ESC 2026 + SCAI)?

The Cardiogenic Shock Management (Adults, ESC 2026 + SCAI) is a emergency clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2026 ESC Guidelines for the management of heart failure (cardiogenic shock) with 2023 ESC Guidelines for the management of acute coronary syndromes.

What guideline is the Cardiogenic Shock Management (Adults, ESC 2026 + SCAI) based on?

This algorithm is based on 2026 ESC Guidelines for the management of heart failure (cardiogenic shock) with 2023 ESC Guidelines for the management of acute coronary syndromes (DOI: 10.1093/eurheartj/ehag100).

What are the limitations of the Cardiogenic Shock Management (Adults, ESC 2026 + SCAI)?

Known limitations include: Adults only. Not for septic, hypovolaemic or other non-cardiac shock.; No drug doses: use local vasoactive infusion protocols. Device choice needs a Shock Team; microaxial pumps and VA-ECMO are available only in some centres.; Evidence of MCS benefit is limited to selected STEMI shock (DanGer Shock); device harms are common.. Individual patient factors may require deviation from these recommendations.

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