Targeted Temperature Management in Cardiogenic Shock Survivors of Cardiac Arrest: A Systematic Review and Meta-Analysis

Targeted temperature management (TTM) is the established standard of care for comatose patients following cardiac arrest, but its safety profile and effectiveness in the subset of patients developing cardiogenic shock are not well defined. Benefits of neuroprotection may be offset by hypothermia-induced hemodynamic instability. This review aimed to evaluate the impact of TTM on mortality and neurological outcomes, specifically in cardiac arrest survivors with cardiogenic shock. PubMed, EMBASE, and Cochrane Central were searched from inception to December 2025 for randomized controlled trials (RCTs) and observational studies comparing TTM (32°C-34°C) versus normothermia or no temperature control in adults with post-cardiac arrest cardiogenic shock. The primary outcome was all-cause mortality. Secondary outcomes included favorable neurological function and lactate clearance. Data were pooled using a random-effects model (DerSimonian-Laird). Certainty of evidence was assessed using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Five studies involving 1,446 patients were included (two RCT sub-analyses and three observational studies). The pooled risk ratio (RR) for all-cause mortality was 1.02 (95% confidence interval (CI) 0.89-1.17; p = 0.76), indicating no significant survival benefit with TTM. Significant heterogeneity was observed (I² = 47.9%), driven by a divergence between observational studies, which favored TTM (RR 0.90; 95% CI 0.63-1.27), and RCTs, which showed a trend toward harm or neutrality (RR 1.05; 95% CI 0.86-1.28). TTM was not associated with improved neurological outcomes or lactate clearance. Meta-regression revealed a temporal trend where more recent, higher-quality studies reported less favorable outcomes for TTM. In survivors of cardiac arrest complicated by cardiogenic shock, TTM at 32°C-34°C was not associated with reduced mortality compared to normothermia. The apparent benefit seen in early observational data is not supported by recent randomized evidence, which raises concerns regarding hemodynamic tolerability. Strict normothermia may be a safer therapeutic strategy in this high-risk population. The certainty of the evidence is very low.