Topic

Cardiology in critical care

Cardiogenic shock, transfusion thresholds, and haemodynamic monitoring.

Mechanical support in cardiogenic shock was assumed to work for decades and mostly does not. The intra-aortic balloon pump did not reduce mortality (IABP-SHOCK II), nor did veno-arterial ECMO, whether deployed immediately (ECMO-CS) or routinely (ECLS-SHOCK). Against that run of failures, the microaxial flow pump reduced 180-day mortality in STEMI-related shock (DanGer Shock) — at the cost of substantially more bleeding and limb ischaemia.

Drug choices are largely settled as ties. Milrinone and dobutamine performed identically (DOREMI). Dopamine matched noradrenaline on mortality while causing far more arrhythmia, which ended its use as a first-line agent (SOAP II). Vasopressin is the exception that puzzles: useless added to catecholamines in septic shock (VASST), but superior as a first-line agent in post-bypass vasoplegia (VANCS).

Invasive monitoring adds risk without benefit — the pulmonary artery catheter did not improve outcomes over careful clinical assessment (ESCAPE). Transfusion thresholds after myocardial infarction remain unresolved: a restrictive strategy met non-inferiority in 666 patients (REALITY) while a trial five times larger could not exclude harm from it (MINT).

Mechanical support in cardiogenic shock

Trial	Year	Therapy	Finding
DanGer Shock	2024	Microaxial flow pump	A microaxial flow pump reduced 180-day mortality in infarct-related cardiogenic shock
ECLS-SHOCK	2023	Veno-arterial ECMO	Veno-arterial ECMO did not reduce mortality in infarct-related cardiogenic shock
ECMO-CS	2023	Veno-arterial ECMO	Immediate ECMO was no better than a conservative strategy with ECMO in reserve
IABP-SHOCK II	2012	Intra-aortic balloon pump	The intra-aortic balloon pump did not reduce mortality in infarct-related cardiogenic shock

Transfusion after myocardial infarction

Trial	Year	Therapy	Effect	Finding
MINT	2023	Liberal transfusion strategy		A liberal transfusion threshold after myocardial infarction gave no significant benefit, but harm could not be excluded
REALITY	2021	Restrictive transfusion strategy		A restrictive transfusion strategy was non-inferior after myocardial infarction

Choice of vasopressor in shock

Trial	Year	Therapy	Effect	Finding
SOAP II	2010	Noradrenaline		Dopamine matched noradrenaline for mortality but caused far more arrhythmias

Extracorporeal CPR

Trial	Year	Therapy	Effect	Finding
INCEPTION	2023	Extracorporeal CPR		Extracorporeal CPR did not improve neurologically intact survival after refractory cardiac arrest

Inotrope choice in cardiogenic shock

Trial	Year	Therapy	Effect	Finding
DOREMI	2021	Milrinone		Milrinone and dobutamine performed identically in cardiogenic shock

Invasive haemodynamic monitoring

Trial	Year	Therapy	Effect	Finding
ESCAPE	2005	Pulmonary artery catheter		The pulmonary artery catheter added adverse events and no benefit over careful clinical assessment

Vasoplegia after cardiac surgery

Trial	Year	Therapy	Effect	Finding
VANCS	2017	Vasopressin		Vasopressin as first-line agent outperformed noradrenaline in post-cardiac-surgery vasoplegia

Key references

Guidelines, standards and reviews for this topic.

Cardiogenic shock
Thiele H, Hassager C. Cardiogenic Shock. N Engl J Med 2026 Jan 1;394(1):62-77. PMID 41467651
Balthazar T, Vandenbriele C, Verbrugge FH, et al. Managing Patients With Short-Term Mechanical Circulatory Support: JACC Review Topic of the Week. J Am Coll Cardiol 2021 Mar 9;77(9):1243-1256. PMID 33663742
Post cardiac surgery
Stephens RS, Whitman GJ. Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med 2015 Jul;43(7):1477-97. PMID 25962078
Stephens RS, Whitman GJ. Postoperative Critical Care of the Adult Cardiac Surgical Patient: Part II: Procedure-Specific Considerations, Management of Complications, and Quality Improvement. Crit Care Med 2015 Sep;43(9):1995-2014. PMID 26136101