Cardiogenic Shock Is Not a Single Entity: Therapeutic Implications

Abstract Cardiogenic shock (CS) is a life-threatening syndrome characterized by systemic tissue hypoperfusion due to inadequate cardiac output. Despite advances in cardiovascular care, mortality remains high, particularly during the first hours and within the first month after onset, underscoring the need for early recognition and tailored therapeutic strategies. The marked heterogeneity of CS has prompted the development of phenotyping approaches encompassing clinical, haemodynamic, aetiological, and emo-metabolic dimensions. Clinically, patients may present as cold and congested, cold and dry, warm and congested, or warm and dry. From an aetiological perspective, CS may be ischaemic, related to de novo heart failure, acute decompensation of chronic heart failure, secondary, or mixed. Mixed shock—characterised by the coexistence of pump failure and inappropriate systemic vasodilation—is associated with higher mortality and rapid clinical deterioration. Advanced phenotyping strategies, including machine learning-based approaches, have identified additional CS subgroups with distinct prognostic profiles and therapeutic requirements. The Society for Cardiovascular Angiography and Interventions (SCAI) classification provides a practical framework for severity stratification and longitudinal monitoring, emphasising the importance of frequent reassessment, particularly in early-stage patients at risk of rapid progression. Management of CS integrates pharmacological therapy—including inotropes and vasopressors—with mechanical circulatory support, tailored to the patient’s phenotype and haemodynamic profile. Optimal care of cardiogenic shock relies on accurate phenotyping, dynamic risk assessment, and personalized therapeutic strategies to improve outcomes while minimising complications.