Mixed cardiogenic–vasodilatory phenotypes in cardiogenic shock: insights from real-world advanced hemodynamic monitoring
F Sahiti, D Schmitt, A Grimm, S Frantz, G Gueder, D WeismannAbstract
Background and aim
Cardiogenic shock (CS) is increasingly recognized as a dynamic syndrome frequently complicated by vasodilatory components and secondary sepsis. The transition between cardiogenic and distributive phenotypes may affect therapeutic decisions, including vasoactive escalation and mechanical circulatory support (MCS). We aimed to characterize hemodynamic phenotypes and treatment trajectories in CS compared with septic shock, with particular focus on mixed shock states in contemporary real-world practice.
Methods
We conducted a retrospective single-center study including adults admitted with CS or septic shock (2015–2018). Advanced hemodynamic monitoring (AHM) was performed using transpulmonary thermodilution (PiCCO). CS severity was graded according to SCAI criteria. Mixed shock was defined as CS with SVRI <2400 dyn·s·m²/cm⁵ or septic shock with CI <2.5 L/min/m². PiCCO-derived CI, SVRI, extravascular lung water index and global end-diastolic volume index, fluid balance, vasoactive therapy, and outcomes were analyzed; primary endpoint was in-hospital mortality.
Results
We analyzed 132 patients (median age 66 years, 73% male), including 75 with CS (predominantly ischemic) and 57 with septic shock. Mixed phenotypes were frequent (79% of CS and 96% of septic shock). At AHM initiation, CI was lower and SVRI higher in CS, clearly separating cardiogenic from vasodilatory profiles (Figure A), whereas mean arterial pressure and lactate were similar. CS patients received more restrictive fluids and more frequent mechanical circulatory support, while septic shock patients underwent larger early resuscitation followed by de-resuscitation (Figure B); norepinephrine was the dominant vasopressor in both entities, with vasopressin mainly used in sepsis and inotropes (dobutamine, levosimendan) in CS. Over time, non-survivors with CS showed progressive deterioration of CI and SVRI, while hemodynamics remained relatively stable in septic shock; lactate clearance was more pronounced in survivors of both groups. Neither single AHM parameters nor mixed-shock definitions discriminated survivors from non-survivors. In-hospital mortality was 45% in CS and 58% in septic shock, with earlier mortality in CS and more protracted mortality in sepsis.
Conclusions
Cardiogenic shock frequently evolves toward mixed cardiogenic–vasodilatory phenotypes. Although AHM refines cardiovascular phenotyping and may support escalation strategies including MCS, single hemodynamic parameters are not prognostic. These findings support a trajectory-based cardiovascular approach to CS rather than static shock categorization.Figure A and B