Women with cardiogenic shock (CS) often experience delays in diagnosis and treatment, possibly due to differences in symptoms and underlying cause. CS in women can be caused by acute myocardial infarction, spontaneous coronary artery dissection, non-ischemic heart failure (women are more likely to have de novo heart failure, takotsubo syndrome, and myocarditis compared to men), valvular heart disease, and peripartum and postpartum cardiomyopathy.
Women with acute myocardial infarction (AMI)-CS often present in a more severe state than men, but are less likely to receive aggressive treatment. Additionally, women are likelier to have non ST elevation myocardial infarction (NSTEMI)-CS. Mortality rates from CS are higher in women than in men, making early recognition and treatment all the more important.
In today's side-by-side comparison, we take a look at the latest guidance from the Society for Cardiovascular Angiography and Interventions (SCAI)/European Association of Percutaneous Cardiovascular Intervention (EAPCI)/Association of Acute Cardiovascular Care (ACVC) and the American College of Cardiology (ACC) regarding cardiogenic shock in women.
Clinical Guidance for Comparison
| Item | SCAI/EAPCI/ACVC Expert Consensus Statement on Cardiogenic Shock in Women | 2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Evaluation and Management of Cardiogenic Shock: A Report of the American College of Cardiology Solution Set Oversight Committee |
|---|---|---|
| Authoring Organization | Society for Cardiovascular Angiography and Interventions, European Association of Percutaneous Cardiovascular Interventions, and Association of Acute Cardiovascular Care | American College of Cardiology |
| Publication Date | May 2025 | March 2025 |
| Graded Recommendations | No | No |
| Uses GRADE | No | No |
| Links | Summary / Full Text | Summary / Full Text |
Key Takeaways
General:
- One of the major differences in these two articles is that the SCAI/EAPCI/ACVC gives consensus tips and evidence gaps specifically for women with cardiogenic shock. The ACC is a consensus report on cardiogenic shock, without gender specific information.
- For the most part both consensus reports offer the same advice, but the SCAI/EAPCI/ACVC report highlights areas where gender disparity exists and emphasizes management tips to close the gap.
Serial Assessments:
- Both consensus reports recommend serial assessments including lactate measurements.
- The ACC also listed several other assessments that should be done frequently: physical exam, pulse checks, other laboratory tests, and blood gases.
Pulmonary Artery Catheter (PAC):
- Both consensus reports recommend considering PAC monitoring to characterize CS, assess severity, and guide treatment.
- Because women are less likely to receive PAC monitoring the SCAI/EAPCI/ACVC report encourages early PAC monitoring for women who continue to have symptoms or have worsening end-organ function despite treatment with strong consideration for PAC monitoring in women on temporary mechanical circulatory support (tMCS).
Temporary Mechanical Circulatory Support (tMCS):
- Both consensus reports advise tMCS when medications are not sufficient to maintain cardiac output and end-organ perfusion.
- The SCAI/EAPCI/ACVC stresses early initiation of tMCS in women with CS.
- Both consensus reports advise selective use of microaxial flow-pumps (Impella).
- SCAI/EAPCI/ACVC advises selective, but early use for women with AMI-CS without coma.
- ACC advises selective use for ST elevation myocardial infarction-CS with left ventricle (LV)-dominant shock. This potentially under-represents women who according to the SCAI/EAPCI/ACVC report are more likely to present with non ST elevation myocardial infarction.
- Neither consensus report recommends routine use of tMCS.
- Both consensus reports agree that more evidence is needed to determine the best tMCS for patients with HF-CS.
Revascularization:
- Both consensus reports state that early revascularization is the primary treatment for AMI-CS.
- The ACC recommends patients with evidence of acute ischemia, in particular those with ST segment elevation be quickly evaluated in the cardiac catheterization laboratory for revascularization if appropriate. This could potentially miss women who more often have non ST segment elevation AMI who may benefit from revascularization.
- The SCAI/EAPCI/ACVC addresses spontaneous coronary artery dissection (SCAD) which is more likely to occur in women. Because most spontaneous coronary artery dissections heal within 30 days, tMCS can allow myocardial rest during healing and revascularization may be considered selectively for those with ongoing ischemia, high risk lesions, or disease that affects multiple vessels.
Comparison of Recommendations:
| Management | SCAI/EAPCI/AC | ACC |
|---|---|---|
| Serial Assessments | Early and frequent assessments of end-organ function including lactate measurements (ie, serial testing every 2-6 hours) are useful to improve early CS diagnosis and risk stratification and to guide the need for early invasive monitoring and advanced therapies. | Clinical suspicion of CS should then be supplemented by readily available laboratory tests, such as a comprehensive metabolic profile assessing for acute kidney and hepatic injury; a venous or arterial blood gas with evidence of metabolic acidosis, and elevated venous or arterial lactate (>2 mmol/L). Serial monitoring, including laboratory analysis (serum creatinine, bicarbonate, arterial or venous pH, central or mixed venous oxygen saturation, lactate, liver chemistries every 2 to 8 hours depending on the phase of care. |
| Pulmonary Artery Catheter (PAC) | Early PAC use in women to assist early CS diagnosis and management may improve survival. PAC should be strongly considered in all patients on tMCS. | In patients presenting with cardiogenic shock, placement of a PA line may be considered to define hemodynamic subsets and appropriate management strategies. Observational data suggest there is utility in applying invasive hemodynamics to characterize the phenotype of CS, assess the severity of shock, and to guide tMCS-related escalation and weaning decisions in the cardiac intensive care unit. |
| Temporary Mechanical Circulatory Support (tMCS) | Anticipated vascular complications should not deter use of potentially lifesaving tMCS; rather, risks should be mitigated with improved techniques for vascular access and follow best practices for indwelling devices. tMCS is advised early for women in CS on inotropes/vasopressors, with persistent low cardiac output, rising lactate levels, or other signs of end-organ hypoperfusion, based on disease-specific and device-specific risk-benefit assessment. Selective early Impella use (either before or early in PCI) in women with AMI-CS without coma is reasonable; however, additional randomized evidence in women is needed. Current evidence does not support routine use of VA-ECMO or IABP in AMI-CS due to lack of mortality benefit and increased risk of vascular complications. Clinical evidence is needed to inform optimal tMCS selection (Impella, VA-ECMO) and timing in women with HF-CS. | Guidance does not specifically address tMCS in women. In patients with cardiogenic shock, temporary MCS is reasonable when end-organ function cannot be maintained by pharmacologic means to support cardiac function. The writing group believes escalation to tMCS with a microaxial flow-pump may be considered in appropriately selected STEMI-CS patients with LV-dominant shock who have evidence of clinical hypoperfusion and/or hemodynamic deterioration. Although tMCS is being increasingly utilized in the treatment of both AMI-CS and HF-CS, routine use of tMCS in all CS patients is strongly discouraged. Further clinical trials are needed to determine which patients are most likely to benefit from tMCS devices, especially among HF-CS patients, which have not been well represented or studied in RCTs. |
| Revascularization | Early revascularization with PCI and/or CABG is the mainstay of therapy in AMI-CS. In patients presenting with SCAD-CS, tMCS support to recovery and selective revascularization strategies in high-risk lesions may be appropriate. | Despite advances in revascularization and increasing use of temporary mechanical circulatory support (tMCS) during the past 2 decades, RCTs have largely failed to identify treatment strategies that reliably improve mortality other than early revascularization for AMI-CS. Electrocardiographic evidence of acute ischemia, particularly ST-segment elevation, should lead to early triage to the cardiac catheterization laboratory, either locally or at the nearest capable facility, and revascularization as appropriate to coronary anatomy. |
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