A comprehensive expert consensus statement on cardiogenic shock in women explains substantial sex-based disparities in diagnosis, treatment, and outcomes. The statement—endorsed by the Heart Failure Society of America—was jointly developed by the Society for Cardiovascular Angiography & Interventions, the European Association of Percutaneous Cardiovascular Interventions, and the Association for Acute Cardiovascular Care.

Cardiogenic shock (CS), a life-threatening condition marked by reduced cardiac output and end-organ hypoperfusion, continues to carry a 30% to 50% in-hospital mortality rate—a figure that has remained largely unchanged over the past two decades despite therapeutic advances. Current evidence shows that women with CS have particularly poor outcomes, due in part to delays in care and lower rates of guideline-recommended interventions.

"Not only do women encounter delays in treatment, but they are less likely to receive guideline-recommended coronary interventions or device therapies compared with men, independent of disease severity," the statement authors write.

The statement addresses the unique clinical features and management of CS in women across various etiologies, including acute myocardial infarction (AMI), spontaneous coronary artery dissection, heart failure, Takotsubo syndrome, peripartum cardiomyopathy, and valvular heart disease. Recommendations are tailored to disease-specific and sex-specific considerations.

Key Findings and Recommendations

Clinical Presentation Differences

Women with AMI-related CS (AMI-CS) tend to have higher left ventricular ejection fraction and similar or lower rates of renal or hepatic insufficiency compared with men. However, hemodynamic studies show worse cardiac contractility and higher predicted mortality for women. As a result, they may be mischaracterized as stable despite ongoing hypoperfusion, which contributes to treatment delays.

Diagnosis and Monitoring

Despite guidance that supports early recognition of CS, the RECOVER III registry showed lactate was measured in only 25% of women vs 50% of men with AMI-CS prior to percutaneous coronary intervention (PCI). The statement recommends early and frequent lactate assessments (every 2 to 6 hours) and end-organ function testing to aid diagnosis and risk stratification.

Pulmonary artery catheter (PAC) monitoring is advised early for women with worsening end-organ function or persistent symptoms. Observational evidence supports a survival benefit with PAC-guided treatment protocols, yet women are less likely to undergo PAC monitoring.

Mechanical Circulatory Support

Temporary mechanical circulatory support (tMCS) can improve perfusion and prevent escalation of vasopressors, but women receive tMCS less frequently than men and have higher rates of vascular complications that require intervention. The statement calls for early initiation of tMCS that is tailored to clinical phenotype and etiology in women with persistent low cardiac output and rising lactate levels.

For AMI-CS, selective early use of the Impella device (prior to or early during PCI) may be reasonable in women without coma. Notably, the international cVAD registry reported a 68.8% survival rate for early Impella use in women vs 24.4% with late use (P = .005).

Routine use of intraaortic balloon pump or venoarterial extracorporeal membrane oxygenation is not supported due to lack of mortality benefit and increased complication risk.

Pregnancy and Peripartum Considerations

Pregnancy-related CS, though rare, carries a maternal mortality rate of nearly 19% when it occurs. Peripartum cardiomyopathy (PPCM) accounts for the majority of peripartum CS cases. Early invasive hemodynamic assessment and rapid initiation of tMCS "are critical to maternal survival," the authors note. They also  emphasize the importance of a multidisciplinary cardio-obstetrics team that includes anesthesiology and critical care.

Bromocriptine may be considered in select patients with PPCM-CS, though it remains investigational in the United States and should be accompanied by anticoagulation due to thrombotic risk.

Disease-Specific Insights

• Takotsubo Syndrome (TTS): Occurs in ~90% women. Up to 10% of TTS cases may progress to CS, with a 23.5% mortality rate in those cases. tMCS is often used as a bridge-to-recovery strategy.

• Valvular Heart Disease: In women with CS and severe aortic or mitral valve disease, transcatheter interventions such as TAVR or mitral edge-to-edge repair (mTEER) are viable options, though data are limited. Women benefit from mTEER at similar rates as men.

Standardizing Care to Reduce Disparities

To address sex-based disparities, the authors strongly endorse standardized, team-based treatment protocols that include:

• Mandatory hemodynamic assessment

• Timely diagnosis

• Early and appropriate use of tMCS

They further recommend improving enrollment of women in CS clinical trials by establishing prespecified quotas. As Figure 3 on page 10 of the source shows, most randomized trials in CS enroll fewer than 25% women.

Conclusion

This expert consensus statement delivers a comprehensive synthesis of current evidence and clinical gaps in the diagnosis and management of CS in women. While women continue to experience poorer outcomes and reduced access to advanced therapies, implementation of standardized care pathways and increased trial representation may help mitigate these disparities. Further research is urgently needed to determine optimal, sex-specific strategies for this high-risk population.

Disclosures can be found in the published consensus statement.

Source: Society for Cardiovascular Angiography & Interventions