Experts’ recommendations for the management of adult patients with cardiogenic shock
SRLF/SFAR/SFC · 2026 · France
Source and licence
- Authors
- Nadia Aissaoui, Clement Delmas, Hamid Merdji et al.
- Title
- Experts’ recommendations for the management of adult patients with cardiogenic shock
- Journal
- Annals of Intensive Care, 2026
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC13081668
Licence statement of the original publication
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Methods
- A high overall level of evidence (GRADE 1+: should be used, treated, done/ GRADE 1-: should not be) led to a “strong” recommendation. A moderate level of evidence resulted in a “moderate” recommendation (GRADE 2+: should probably/ GRADE 2-: should probably not). When the literature was insufficient or nonexistent, expert opinion was used to formulate recommendations (experts suggest or can be).
- The proposed recommendations were presented and discussed at two expert meetings. Each expert rated each recommendation on a scale ranging from 1 (complete disagreement) to 9 (complete agreement). All experts voted on recommendations. The collective rating was established using a GRADE grid methodology. To approve a recommendation, at least 50% of the experts had to agree, and fewer than 20% could disagree. For strong agreement, at least 70% of the experts had to agree. If strong agreement was not achieved, the recommendations were revised and re-rated to reach consensus. The wording of all recommendations strictly followed the predefined GRADE-based methodology. In this framework, the use of terms such as ‘should’ versus ‘should probably’ directly reflects the strength of the recommendation and the level of evidence, with ‘should probably’ corresponding to a moderate recommendation (GRADE 2), derived from a structured expert consensus and formal voting process integrating both evidence quality and degree of agreement [14,15].
Results
- Twenty-three PICO questions were identified, leading to 41 recommendations regarding management of CS in adult patients. Seven recommendations were scored with a high level of evidence (Grade 1), 11 with a moderate level of evidence (Grade 2) and 17 with a low level of evidence (Expert opinion). In 6 cases, the experts were not able to give an answer
- R1CS patients should probably be managed by a multidisciplinary CS team.Level of evidence, grade 2+
- R2Experts suggest discussing and managing patients with CS through a structured regional network centered on specialized shock expert centers with a multidisciplinary shock team, ensuring adequate referral and management of patients based on available resources and expertise.Level of evidence, expert opinion
- R3In patients with CS, the experts suggest discontinuing chronic heart failure treatments at the time of CS diagnosis so as to avoid worsening of hemodynamic status.Level of evidence, expert opinion
- R4Experts suggest not initiating diuretics in patients with CS and significant hemodynamic instability characterized by the need for high-dose vasopressors and/or inadequate cardiac output.Level of evidence, expert opinion
- R7In the absence of evidence, experts make no recommendation regarding the interest of sedation analgesia to decrease myocardial oxygen consumption in CS patients without respiratory or neurological failure.
- R8In CS patients, experts suggest considering homologous red blood cell transfusion when hemoglobin level is less than 8 g/dL.
- R9Therapeutic hypothermia should probably not be used in CS patients.Level of evidence, grade 2-
- R13For patients presenting with CS related to aortic regurgitation, the experts suggest activating the CS team to discuss and decide on the timing and the choice of the best strategy to apply (percutaneous versus surgical approach) according to the underlying process, the patient’s profile and local expertise.Level of evidence: expert opinion
- R15In the absence of data in the literature, the panel makes no recommendation regarding increasing the heart rate in CS patients.
- The panel suggests to apply criteria for intubation based on the recent consensus conference on oxygen therapy in acute hypoxemic respiratory failure [137]: cardiac or respiratory arrest, shock requiring vasopressor, persistent or worsening hypoxemia despite maximal oxygenation strategy, recurrent desaturation episodes with SpO2 < 86%, clinical signs of respiratory distress, appearance or worsening of vigilance disorders, respiratory or mixed acidosis, tachypnea with respiratory rate > 30 or worsening respiratory rate, bronchial congestion or copious secretions, agitation, intolerance to oxygenation modality.
Renal replacement therapy
- R17Experts make no recommendation regarding the early use of renal replacement therapy for patients with CS requiring fluid removal.
- R21There is no evidence to recommend implantation of temporary mechanical circulatory support before rather than after percutaneous coronary intervention in AMI-CS patients.
- R22Experts suggest the initiation of guidelines regarding long-term cardiovascular treatments after the resolution of shock and before hospital discharge. Remark: Experts suggest discussing therapeutic implementation within the CS team and planning specialized follow-up with a cardiologistLevel evidence: expert opinion
- R23There is no evidence to recommend early mobilization in CS patients.
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.
Contents of the original publication
The section headings of the original.
- Introduction
- Methodology
- Expert panel
- Scope and definitions
- Methods
- Results
- Renal replacement therapy
- Sustainability considerations in the management of patients with cardiogenic shock
- Conclusion and perspectives
- CRediT authorship contribution statement
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