Advanced hemodynamic monitoring of the patient with acute heart failure and cardiogenic shock

Purpose of review To provide a practical, physiology-driven framework for advanced hemodynamic monitoring in patients with acute heart failure (AHF) and cardiogenic shock, highlighting and supporting clinicians in integrating monitoring tools into an individualized bedside approach. Recent findings Cardiogenic shock is increasingly recognized as a heterogeneous syndrome involving not only impaired cardiac output, but also systemic inflammation, vasoplegia, tissue hypoperfusion and multiorgan dysfunction. Recent studies have emphasized phenotype-based approaches for both diagnosis and treatment, integrating clinical evaluation, echocardiography, invasive hemodynamics and tissue perfusion markers. Machine learning derived phenotypes have further identified cardiorenal and cardiometabolic profiles associated with distinct prognostic implications. Critical care echocardiography has a central role for rapid diagnosis and serial reassessment, while transpulmonary thermodilution and pulmonary artery catheterization provide complementary information to echocardiography in refractory or complex cases. Summary Hemodynamic monitoring in AHF and cardiogenic shock should rely on individualized, multimodal and dynamic integration of clinical examination, biomarkers, echocardiography and invasive monitoring. The main goals are to define the underlying phenotype, assess congestion and tissue hypoperfusion, and evaluate treatment response. Echocardiography remains the cornerstone of bedside assessment, whereas invasive monitoring should be reserved for selected high-risk patients with persistent or complex shock.