REVIEW

CURRENT
OPINION Hemodynamic monitoring in cardiogenic shock
Tyler J. VanDyck and Michael R. Pinsky

Purpose of review
Cardiogenic shock remains a major cause of mortality today. With recent advancements in invasive
mechanical support strategies, reperfusion practice, and a new classification scheme is proposed for
cardiogenic shock, an updated review of the latest hemodynamic monitoring techniques is important.
Recent findings
Multiple recent studies have emerged supporting the use of pulmonary artery catheters in the cardiogenic
shock population. Data likewise continues to emerge on the use of echocardiography and biomarker
measurement in the care of these patients.
Summary
The integration of multiple forms of hemodynamic monitoring, spanning noninvasive and invasive
modalities, is important in the diagnosis, staging, initial treatment, and subsequent management of the
cardiogenic shock patient.
Keywords
cardiogenic shock, echocardiography, hemodynamic monitoring, pulmonary artery catheterization

INTRODUCTION observational study integrating these various forms

Mortality from cardiogenic shock remains elevated, of hemodynamic monitoring with a multidisciplin-
ranging from 40 to 67% among the most severe of ary diagnostic and therapeutic team (SHOCK Team)
cases [1], despite advances in recent years in invasive approach showed improvement in 30-day survival
mechanical support and reperfusion practice. In effort rates from 47% preintervention to 58% and 77% in
to improve disease state stratification, recent guide- the two subsequent years postimplementation [3].
lines endorsed by a multitude of medical societies have The use of advanced monitoring techniques should
been released. These guidelines, proposed by the Soci- complement, and not replace, targeted clinical exam-
ety for Cardiovascular Angiography and Intervention ination of other markers of perfusion and cardiac
(SCAI), outline a new classification scheme for the function, such as level of consciousness, respiratory
&&
stages of cardiogenic shock (Table 1) [2 ]. Sequential effort, lung sounds, bowel sounds, capillary refill
hemodynamic monitoring is essential for the accurate time, urine output, edema, and skin temperature.
diagnosis, staging, risk stratification, and manage-
ment of cardiogenic shock. There is not a single moni-
Peripheral arterial catheterization
toring approach for all patients. Various forms of
monitoring allow the identification of patients requir- Peripheral arterial catheterization is recommended
ing medical therapy and/or invasive mechanical sup- to allow for continuous monitoring of systolic blood
port, and to gauge the response to therapy. This review pressure (SBP) and mean arterial pressure (MAP)
&&

focuses on publications arising within the last two [4 ]. This facilitates easy and frequent titration of
years as discovered using PubMed and Google Scholar inotropes and/or vasopressors, which are commonly
search engines.
Department of Critical Care Medicine, University of Pittsburgh, Pitts-
burgh, Pennsylvania, USA
FORMS OF HEMODYNAMIC MONITORING
Correspondence to Michael R. Pinsky, MD, Department of Critical Care
Forms of hemodynamic monitoring that continue to Medicine, University of Pittsburgh, 638 Scaife Hall, 3550 Terrace Street,
show promise for the management of cardiogenic Pittsburgh, Pennsylvania 15261, USA. Tel: +1 412 383 3487;
shock include peripheral arterial catheterization, pul- e-mail: pinsky@[Link]
monary artery catheterization (PAC), biomarker mea- Curr Opin Crit Care 2021, 27:454–459
surement, and serial echocardiography. A recent DOI:10.1097/MCC.0000000000000838

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 Hemodynamic monitoring in cardiogenic shock VanDyck and Pinsky

long included hypotension (variably defined as

KEY POINTS SBP < 90, MAP < 60 or >30 mmHg less than baseline),
 Serial hemodynamic monitoring is paramount to the accompanied by tissue hypoperfusion, as core com-
diagnosis, initial treatment, and subsequent ponents of the definition of cardiogenic shock
&& &&
management of cardiogenic shock. [2 ,4 ]. A recent retrospective 1,002 patient analysis
of cardiogenic shock patients found an inverse rela-
 All patients with cardiogenic shock should have an
tionship between the mean MAP in the first 24 h and
arterial line placed for blood pressure monitoring and
titration of vasoactive infusions. hospital mortality, with significantly increased mor-
tality in patients with a mean MAP < 65 mmHg [6].
 Invasive monitoring with a pulmonary artery catheter
should be considered, particularly in patients with
diagnostic uncertainty or in those patients who fail to Right heart & pulmonary artery
respond to initial therapy. catheterization
 Echocardiography should be used early in the Right heart catheterization with the placement of a
diagnosis of cardiogenic shock and serial assessments PAC facilitates invasive measurement of intracardiac
may aid management. pressures, the performance of thermodilution cardiac
output measures, and measurement of mixed-venous
oxygen saturation. These data can be used to calculate
needed in cardiogenic shock patients with advanced the cardiac index, cardiac power output/index (CPO/
disease. Of additional clinical importance, a recent CPI), and pulmonary artery pulsatility index [7]. These
analysis comparing invasive and noninvasive (aus- measures interpreted together provide a robust assess-
cultatory or oscillometric) approaches in cardio- ment of left and right heart systolic performance. The
genic shock patients showed that noninvasive data can be used to make diagnostic and treatment
methods tend to overestimate blood pressure during decisions, such as the initiation and discontinuation
episodes of hypotension [5]. Thus, if arterial pressure of appropriate mechanical support devices based on
&&
values need to be accurately measured, invasive the degree and type of ventricular dysfunction [8,9 ].
monitoring is recommended. As an example, CPO 0.53 was the strongest predictor
Blood pressure can vary with the stage of cardio- of in-hospital mortality in patients with acute myo-
genic shock, but basic consensus definitions have cardial infarction complicated by cardiogenic shock

Table 1. Hemodynamic characteristics of the SCAI classification of cardiogenic shocka

Stage Physical Examination Biochemical markers Hemodynamics

A. At Risk Normal CVP, no rales, warm, Normal labs, lactate SBP > 100 or normal for pt. If done:
good peripheral pulses, and renal function CI 2.5, CVP < 10, SvO2 > 65%
normal mentation
B. Beginning CS "CVP, rales, good peripheral Minimal renal SBP < 90 or MAP < 60 or > 30
pulses, normal mentation functional decrease, HR 100. If done: CI
impairment, 2.2, SvO2 65%
elevated BNP
C. Classic CS May include any: May include any: May include any:
Looks unwell, panicked, ashen, Lactate > 2, doubling SBP < 90, MAP < 60 or > 30
volume overload, rales, Killip creatinine or 50% decrease, and drugs/device used
class 3–4, cold/clammy, drop in GFR, to maintain BP above target,
altered MS, decreased UO Increased LFTs, CI < 2.2, Ppao > 15, CVP/Ppao
elevated BNP 0.8, PAPI < 1.85, CPO 0.6
D. Deteriorating/Doom Any of Stage C Any of Stage C and Any of Stage C and require multiple
deteriorating pressors, mechanical circulatory
support to maintain flow
E. Extremis Near pulselessness, cardiac ‘‘Trying to die’ pH ’ SBP without resuscitation, pulseless
collapse, mechanical 7.2, lactate 5 electrical activity, refractory VT/
ventilation, defibrillator used VF, hypotension despite maximal
support

a
BNP, brain natriuretic peptide; CI, cardiac index; CPO, cardiac power output; CS, cardiogenic shock; CVP, central venous pressure; GFR, glomerular filtration
rate; LFTs, liver function tests; MAP, mean arterial pressure; MS, mental status; PAPI, pulmonary artery pulsatility index; Ppao, pulmonary arterial occlusion
pressure; pt, patient; SBP, systolic blood pressure; SCAI, Society for Cardiovascular Angiography and Intervention; SvO2, mixed venous O2 saturation; UO, urine
&&
output; VT/VF, ventricular tachycardia/fibrillation. Modified from Baran et al. [2 ].

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Cardiogenic shock

(AMICS), from the SHOCK registry [10]. The use of cardiogenic shock patients, however, should be cau-
CPO as a predictor of mortality has been shown to be tioned. The trial was designed to avoid the inclusion
valid in patients undergoing early mechanical sup- of unstable patients who might require urgent PA
port, and CPO was superior to SBP measurements [11]. catheterization to guide management, including
That finding was not universal, however, and data are patients with previous inotrope requirement during
conflicting in a separate cohort from the Cardiogenic the hospitalization or with severe acute kidney inju-
Shock Working Group registry, with a higher propor- ries. Despite the previous neutral data described,
tion of cardiogenic shock due to decompensated heart multiple societies and experts in their most recent
failure, where they found that CPO was not signifi- statements continue to recommend PAC use in
cantly predictive of mortality. They did, however, cardiogenic shock patients, particularly among
&& && &&
identify biventricular and right ventricular congestion complicated patient presentations [2 ,4 ,9 ].
as significant mortality predictors, and suggest further Additionally, recent international survey data has
study of CPO in its application to different cohorts of identified the use of a PAC in cardiogenic shock
cardiogenic shock patients [12]. Accordingly, CPO, patients by a majority of practicing physicians
though useful, may not replace systolic and MAP- [15]. This continues to be an area of evolving
based classifications in assessing risk. research.
The hemodynamic presentation of cardiogenic A growing body of evidence in recent years has
shock can be variable, based on the degree of com- supported PAC use in cardiogenic shock patients. A
pensatory increases in systemic vasomotor tone, the recent multicenter retrospective review from the
underlying etiology, and any concomitant systemic Cardiogenic Shock Working Group analyzed out-
inflammatory response syndrome. The data from comes in 1,414 cardiogenic shock patients, stratified
the PAC can identify such mixed forms of shock by SCAI stage and by the degree of PAC use (com-
and stratify a patient’s position in the classic frame- plete data, incomplete data, or no PAC data) prior to
&
work of ‘wet vs. dry’ and ‘warm vs. cold,’ which initiation of mechanical support [16 ]. They found
guide the approach for vasopressors and volume significant differences in mortality between PAC-
management (Table 2). Unmasking mixed shock use groups in the overall cohort as well as each SCAI
(patients in cardiogenic shock who have a promi- stage. The patients with complete PAC assessment
nent vasoplegic component) and those with normo- had the lowest in-hospital mortality across all SCAI
tensive cardiogenic shock (patients with stages. The findings were consistent with other pub-
hypoperfusion due to poor forward flow but with lished reports, including a single-center retrospec-
compensatory elevated vascular tone) are two tive study published in 2017 that found lower short
important diagnoses facilitated by PAC placement and long-term mortality associated with PAC use,
&&
[4 ]. Furthermore, the use of serial hemodynamic although only for the subset of cardiogenic shock
measurements gauges response to therapy and can patients without acute coronary syndrome [17]. This
identify the need for escalation of support. is in addition to other multicenter registry data
Routine use of PACs in critical care medicine has published in 2019 showing an association between
been widely debated over the past few decades, PAC use and lower mortality and in-hospital cardiac
&
secondary to neutral meta-analysis data on mortal- arrest rates [18 ]. Similar findings of improved mor-
ity and survival benefit for critically ill patients [13]. tality have been seen specifically for AMICS patients
Additionally, the ESCAPE trial evaluated the effect who underwent Impella placement, with and with-
of PAC for patients with severe symptomatic heart out PAC monitoring [19]. Although these studies are
failure and yielded overall neutral results, with no not without limitations, they represent the stron-
clinical survival benefit and no excess mortality, gest observational evidence in support of ongoing
despite a predictable increase in PAC-related adverse PAC use in the diagnosis and management of
events [14]. The broad application of this trial to all cardiogenic shock.

Table 2. Variable Hemodynamic Phenotypes of Cardiogenic Shocka

‘Dry’ ’Wet’

‘‘Warm’ Low SVR with Normal or Decreased Low SVR with Elevated Ppao ¼ Mixed Shock
Ppao ¼ Vasodilatory (not Cardiogenic) Shock (Cardiogenic Shock with vasoplegia)
’Cold’ Elevated SVR with Normal or Decreased Elevated SVR with Elevated Ppao ¼ Classic
Ppao ¼ Euvolemic Cardiogenic Shock Cardiogenic Shock

a
Ppao, pulmonary artery occlusion pressure; SVR, systemic vascular resistance.

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 Hemodynamic monitoring in cardiogenic shock VanDyck and Pinsky

Echocardiography AMICS identified arterial lactate measured at 8 h

Since echocardiographic assessment can occur (using a cutoff of 3.1) as the best predictor of mor-
immediately and is noninvasive, it should be per- tality, superior to baseline measurement and calcu-
&

formed urgently in the assessment of a possible lation of lactate clearance [27 ]. Another recent
&&
cardiogenic shock patient [4 ]. A basic assessment secondary analysis of cardiogenic shock patients
of left and right ventricular contractility can help found that lactate measurements at 6, 12, and
support or refute the diagnosis of cardiogenic shock, 24 h were predictors of 30-day mortality, and addi-
as well as identify emergent life-threatening etiolo- tionally that relative change in lactate in the first
gies of shock such as cardiac tamponade. More 24 h predicts survival [28]. In a separate cohort of
detailed examination can assess right and left heart AMICS patients who underwent percutaneous cor-
geometry, quantify diastolic dysfunction, reveal onary angiography and Impella placement, combin-
regional wall motion abnormalities (suggestive of ing lactate levels with hemodynamic data (lactate
coronary artery disease), acute or chronic valvular >4 or <4 and CPO > 0.6 or <0.6) at 12–24 h post-
abnormalities, outflow obstruction, as well as procedure was the best predictor of survival [11].
mechanical complications such as septal or ventric- Troponin and brain natriuretic peptide are useful
ular free wall rupture, papillary muscle rupture, or indicators for acute coronary syndrome and acute
&&
&
chordae tendineae rupture [20 ,21]. Echocardiogra- heart failure [2 ], respectively, but their role specifi-
phy can also be used to noninvasively estimate cally for serial hemodynamic monitoring of cardio-
cardiac output, pulmonary artery systolic pressure genic shock is less well established. Many additional
and via calculation, systemic vascular resistance novel biomarkers continue to be studied, but none
[22]. A recent large 5,453 patient retrospective data- of these have entered the mainstream of cardiogenic
base study showed that multiple echocardiographic shock management at the present time [29].
parameters (including low stroke volume index and
high E/e0 ratio) correlated with SCAI stages and
Other noninvasive and minimally invasive
mortality, particularly among patients with less
& modalities
severe stages of shock [23 ]. A recent randomized
controlled trial evaluated the effect of serial minia- As the use of PAC fell out of favor in the early 2000s,
ture transesophageal echocardiography (TEE) on multiple additional noninvasive modalities were pro-
time to resolution of hemodynamic instability in posed as alternatives to PAC’s to measure cardiac
ICU patients with undifferentiated circulatory output [30]. These modalities include the chest bio-
&
shock [24 ]. There was no difference in the resolu- reactance techniques, minimally invasive pulse-con-
tion of hemodynamic instability at their primary tour analyses, and transpulmonary dilution.
endpoint of 6 days, but there was an improvement The chest bioreactance technique is used by the
with TEE when the data was analyzed for the first Starling Non-Invasive Cardiac Output Monitor
72 h. This suggests a role for TEE but needs to be (NICOM) device (Baxter Medical, Chicago). The
studied in the cardiogenic shock population exclu- NICOM device was previously evaluated for use in
sively and in the larger numbers to verify. Finally, a a variety of intensive care unit settings and was
small retrospective study found that the ratio of shown to have acceptable accuracy, precision, and
corrected left ventricular ejection time to pulmo- responsiveness for cardiac output measurements in
nary artery wedge pressure independently predicted comparison to PAC thermodilution [31,32]. A more
successful weaning from veno-arterial extracorpo- recent study, however, specifically evaluated the use
real support [25]. These studies together provide of NICOM for cardiogenic shock patients and showed
important evidence supporting the ongoing use of poor correlation compared to both Fick and PAC
echocardiography in the hemodynamic assessment thermodilution [33]. Potentially, the poor correla-
of patients with cardiogenic shock. tion of NICOM may be related to the thoracic fluid
overload and low flow state seen in cardiogenic shock
patients affecting such impedance-based measure-
Blood chemistries ments. To our knowledge, the use of NICOM for
Although no particular biomarker is diagnostic of hemodynamic monitoring in cardiogenic shock
cardiogenic shock, serial monitoring of several lab- has not been endorsed in any societal guidelines.
oratory markers can support the diagnosis and Pulse-contour analysis devices have similarly
monitor the progress of treatment. Although non- been proposed as noninvasive or minimally NIC-
specific, monitoring basic chemistries such as liver OMs but have not been validated specifically for the
function tests, renal function tests, and lactate is cardiogenic shock population and have not been
recommended for an assessment of end-organ per- endorsed in any societal guidelines or studied in
fusion [26]. A recent large sub-study of patients with recent literature. Transthoracic dilution measures,

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Cardiogenic shock

2. Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus
using a central venous and arterial catheter, calcu- && statement on the classification of cardiogenic shock:. Catheter Cardiovasc
late cardiac output, global end-diastolic volume, Interv 2019; 94:29–37.
This document proposes a new staging system for cardiogenic shock and was
and extravascular lung water. In a recent trial for endorsed by the American College of Cardiology (ACC), the American Heart
AMICS, investigators compared the use of PiCCO to Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society
of Thoracic Surgeons (STS).
a control group utilizing central venous pressure, 3. Tehrani BN, Truesdell AG, Sherwood MW, et al. Standardized team-based
heart rate, and blood pressure monitoring alone care for cardiogenic shock. J Am Coll Cardiol 2019; 73:1659–1669.
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[34]. The study demonstrated favorable outcomes && contemporary management of cardiogenic shock - a position statement from
in Acute Physiology And Chronic Health Evaluation the Heart Failure Association of the European Society of Cardiology. Eur J
Heart Fail 2020; 22:1315–1341.
and Sequential Organ Failure Assessment scores, This is the most recent position statement from the European Society of Cardiology
length of stay, and cardiac indices in the days fol- outlining the diagnosis and management of cardiogenic shock.
5. Seidlerová J, Tůmová P, Rokyta R, Hromadka M. Factors influencing the
lowing initiation. To our knowledge, the use of this accuracy of noninvasive blood pressure measurements in patients admitted
device for cardiogenic shock management has not for cardiogenic shock. BMC Cardiovasc Disord 2019; 19:150.
6. Burstein B, Tabi M, Barsness GW, et al. Association between mean arterial
been endorsed in any societal guidelines. These pressure during the first 24 h and hospital mortality in patients with cardio-
minimally invasive devices can all be used to esti- genic shock. Crit Care 2020; 24:513.
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mate cardiac output but do not give the additional and clinical application. Eur J Heart Fail 2020; 22:32–38.
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&& patients with cardiogenic shock undergoing mechanical circulatory support.
CONCLUSION Circulation 2020; 141:1184–1197.
This expert opinion paper from a consortium of cardiogenic shock researchers
A significant new amount of literature has emerged discusses multimodal hemodynamic monitoring in the cardiogenic shock
population.
over the past several years surrounding the diagnosis 10. Fincke R, Hochman JS, Lowe AM, et al. Cardiac power is the strongest
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16. Garan AR, Kanwar M, Thayer KL, et al. Complete hemodynamic profiling with
Acknowledgements & pulmonary artery catheters in cardiogenic shock is associated with lower in-
hospital mortality. JACC Heart Fail 2020; 8:903–913.
None. This large multicenter retrospective study is one of the most recent studies
suggesting clinical benefit of PAC in cardiogenic shock.
Financial support and sponsorship 17. Rossello X, Vila M, Rivas-Lasarte M, et al. Impact of pulmonary artery catheter
use on short- and long-term mortality in patients with cardiogenic shock.
M.R.P., MD is supported by NIH grants GMS117622, Cardiology 2017; 136:61–69.
18. Hernandez GA, Lemor A, Blumer V, et al. Trends in utilization and outcomes of
NR013912, HL144692, HL141916 and EB029751 and & pulmonary artery catheterization in heart failure with and without cardiogenic
DoD funding W811XMH-18-SB-AA1 and W81XWH- shock. J Card Fail 2019; 25:364–371.
This retrospective cohort study found an association between PAC use and lower
19-C-0101. M.R.P., MD received Honoria for consulting mortality among cardiogenic shock patients.
with Baxter Medical and Exostat Medical. T.J.V., MD 19. O’Neill WW, Grines C, Schreiber T, et al. Analysis of outcomes for 15,259 US
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Conflicts of interest & ment in cardiogenic shock. Herz 2020. doi: 10.1007/s00059-020-05000-3.
(Epub ahead of print).
There are no conflicts of interest. This comprehensive review paper outlines the applications of echocardiography
for the diagnosis and management of cardiogenic shock.
21. Boissier F, Bagate F, Mekontso Dessap A. Hemodynamic monitoring using
trans esophageal echocardiography in patients with shock. Ann Transl Med
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