Learning from cardiogenic shock deaths: A comparative analysis between hypotensive and normotensive cardiogenic shock

Aims
This study characterizes the under-recognized normotensive cardiogenic shock (CS) phenotype by analysing fatal cases, comparing haemodynamics, shock trajectories, and management gaps with hypotensive CS.
Methods and results
We analysed 112 patients who died from CS between 2017 and 2022. Patients > 70 were excluded due to local eligibility criteria. Normotensive (n = 51) and hypotensive CS (n = 61) had similar degrees of cardiac impairment, with cardiac indices well below 2.0 L/min/m2 and LVEF < 35%. Both groups exhibited comparable end-organ dysfunction, including lactate levels (7.0 ± 5.0 vs. 6.1 ± 5.6 mmol/L, P = 0.441) and acute liver injury (51–56%). Hypotensive CS typically followed a predictable decline in shock stage [75.4% deteriorated to Society for Cardiovascular Angiography Interventions (SCAI) stages D–E], whereas normotensive CS demonstrated less predictable trajectories, with 51% showing apparent stability before rapid deterioration and death. Receiver operating characteristic analysis revealed that only the rise in serum creatinine weakly predicted deterioration to advanced SCAI stages (Area under the curve 0.62, P = 0.035), while initial lactate and liver function tests lacked predictive value. Normotensive cases had a median 14 h longer referral window from onset of CS but were referred less frequently. Twenty-six were considered potential candidates for advanced heart failure therapy but were not referred.
Conclusion
Normotensive and hypotensive CS share similar degrees of hypoperfusion but differ in their shock trajectories. The delay in referrals for normotensive CS highlights the need for earlier recognition of this phenotype and standardized protocols to ensure timely referrals for mechanical circulatory support.