Shock Academic Research Consortium framework: The modern approach to CS is anchored in the use of standardized classification systems and structured guideline-based treatment pathways. The 2025 ACC Expert Consensus Statement on CS proposes the Shock Academic Research Consortium to classify CS by etiology and improve consistency across research and care. ^, As shown in Figure 1 , this framework divides CS into four main groups: AMI-related CS, HF-related CS (de novo and acute-on-chronic), postcardiotomy CS, and secondary CS from nonmyocardial etiologies such as valvular, arrhythmic, or mechanical complications. While AMI-CS was historically the leading etiology, HF-CS has now surpassed it. In a 2024 multinational registry, the use of SHARC definitions showed that 27% of CS cases were attributable to AMI, 59% to HF, and 14% to secondary etiologies such as valvular or arrhythmic disease, as shown in Figure 2 . ⁹

Classifying cardiogenic shock by the Shock Academic Research Consortium framework. This framework divides CS into four groups by etiology: AMI-related CS, HF-related CS (de novo and acute-on-chronic), postcardiotomy CS, and secondary CS from non-myocardial etiologies such as valvular, arrhythmic, or mechanical complications. AMI = acute myocardial infarction; CS = cardiogenic shock; HF = heart failure. Adapted from Waksman et al.

Division of cardiogenic shock cases by etiology. A 2024 multinational registry used the Shock Academic Research Consortium definitions to divide cases of CS by etiology, establishing HF as the leading etiology of CS. Fifty-nine percent of CS etiologies were attributable to HF, while only 27% were attributable to AMI and 14% to secondary etiologies such as valvular or arrhythmic disease. AMI = acute myocardial infarction; CS = cardiogenic shock; HF = heart failure. Adapted from Berg et al.

Mortality by subtype ranges from 25% in acute-on-chronic HF-CS, to 31% in de novo HF-CS, and reaches 41% in AMI-C. In an observational study from 1999 to 2020, mortality related to HF-CS remained stable in the early 2000s but rose by 13.3% annually thereafter, while AMI-CS mortality declined by 6.9% during the early 2000s and has since plateaued, as shown in Figure 3 . Additional data published in 2024 indicate that patients with HF-CS have a significantly elevated risk of needing cardiac replacement therapy and experience postdischarge mortality rates roughly twice those observed in AMI-CS (19.3% vs 8.5%). Beyond traditional categories, the COVID-19 pandemic brought attention to myocarditis as an etiology of shock. Population-level data from California demonstrated that patients hospitalized with COVID-19 and myocarditis had over a fourfold increased risk of developing CS, along with significantly higher rates of cardiac arrest and in-hospital mortality.

Temporal trends of mortality of acute myocardial infarction (AMI) versus heart failure (HF) induced cardiogenic shock. In an observational study from 1999 to 2020, mortality related to HF-CS remained stable in the early 2000s but rose annually thereafter, while AMI-CS mortality declined during the early 2000s and has since plateaued. CS = cardiogenic shock. Adapted from Ghajar et al.

Society for Cardiovascular Angiography and Interventions classification: In parallel to etiologic classifications, the 2025 ACC Expert Consensus Statement on Cardiogenic Shock also proposes the Society for Cardiovascular Angiography and Interventions CS staging system, as shown in Figure 4 . This tool defines CS across five levels of hemodynamic severity: stage A (at risk), stage B (beginning), stage C (classic shock), stage D (deteriorating), and stage E (extremis). This framework allows clinicians to track progression and guide stepwise management, prioritizing hemodynamic assessment, invasive monitoring, and early activation of multidisciplinary shock teams. While this system has improved acute risk stratification and prediction of short-term mortality, its association on longer term recovery is less well established. Together, Shock Academic Research Consortium framework and Society for Cardiovascular Angiography and Interventions classification offer complementary approaches to CS subdivision, both integrated into modern therapeutic algorithms.

The Society for Cardiovascular Angiography and Interventions classification of cardiogenic shock. This tool defines CS across five levels of hemodynamic severity: stage A (at risk), stage B (beginning), stage C (classic shock), stage D (deteriorating), and stage E (extremis). In doing so, it allows clinicians to track CS progression and guide stepwise management. CS = cardiogenic shock. Adapted from Waksman et al.

Alongside advances in classification, treatment interventions for CS have been subject to major changes. Current treatment of CS can be grouped into three broad categories. The first is pharmacologic therapy, which includes vasopressors and inotropes used to stabilize perfusion. Despite being used nearly universally as an initial step, pharmacologic support alone is rarely sufficient, and most patients require additional interventions. A second strategy is early revascularization, most often by percutaneous coronary intervention, which is employed in up to 80% of patients with acute ST elevation myocardial infarction. The third option is mechanical circulatory support, including intra-aortic balloon pumps (IABP), ventricular assist devices (VADs) such as Impella, and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Mechanical circulatory support is used in roughly 40% of contemporary CS cases, often as a bridge to recovery, ventricular support, or transplantation. Alongside these evolving treatments, system-level strategies, such as multidisciplinary shock teams, CICU liberation bundles, and family engagement programs, have also been introduced. These advances in treatment correlate with declines in in-hospital mortality; however, their impact on long-term survivorship remains poorly studied.

Pharmacologic therapy remains the nearly universal first step in the management of CS, with vasopressors and inotropes serving as initial measures to stabilize perfusion. In the United States, commonly used vasopressors include norepinephrine, epinephrine, dopamine, and vasopressin, while dobutamine and milrinone are the principal inotropes. These agents are effective for immediate hemodynamic support, but none have been shown to improve mortality. The SOAP II trial is the largest trial comparing vasopressors in shock, randomizing over 1600 shock patients (including a subgroup of 280 patients with CS) to dopamine or norepinephrine. In the overall study population, norepinephrine was associated with fewer arrhythmic events, but there was no significant difference in 28-day mortality between the two agents, as shown in Figure 5 . However, in the CS subgroup, dopamine was linked to a significantly higher 28-day mortality and marked as increased risk of tachyarrhythmias compared with norepinephrine.

Probability of survival in the SOAP II trial. In the SOAP II trial comparing vasopressors in CS, there was no significant difference in 28-day mortality with dopamine use and norepinephrine use. CS = cardiogenic shock. Adapted from De Backer et al.

Similarly, the DOREMI trial evaluated inotropes by randomizing 192 patients with CS to either milrinone or dobutamine. The primary composite outcome, encompassing death, cardiac arrest, transplant, and other complications, occurred at similar rates in both groups, as shown in Figure 6 . These results suggest that while inotropes remain crucial for hemodynamic stabilization, the choice between milrinone and dobutamine does not affect mortality outcomes. While pharmacologic agents can temporarily improve perfusion, no evidence to date has demonstrated mortality or long-term survivorship benefits from their use alone. Consequently, pharmacologic management primarily serves as a bridge to definitive interventions such as revascularization and mechanical circulatory support.

Rate of primary composite outcome occurrence in the DOREMI trial. In the DOREMI trial comparing dobutamine with milrinone in CS, primary composite outcome, encompassing death, cardiac arrest, transplant, and other complications, occurred at similar rates in both groups. CS = cardiogenic shock. Adapted from Mathew et al.

Revascularization is a cornerstone of managing CS secondary to AMI. Percutaneous coronary intervention is most often performed because of its speed and lower procedural risk, while coronary artery bypass grafting is generally not used in CS. The landmark SHOCK trial in 1999 compared early revascularization to standard medical therapy in patients with AMI complicated by CS. As shown in Figure 7 , there was no significant difference in 30-day mortality between the two groups. However, longer term outcomes demonstrated a clear survival benefit for early revascularization. Mortality at 6 months was significantly lower in the patients who received revascularization (50.3% vs 63.1%), with this survival advantage persisting at 1 year, establishing revascularization as a key therapy for AMI-induced CS. The CULPRIT-SHOCK trial in 2017 refined percutaneous coronary intervention strategy in AMI-induced CS. It tested whether patients with multivessel coronary disease should undergo an immediate multivessel strategy or a more limited culprit-vessel-only strategy. The findings suggested culprit-lesion-only revascularization significantly reduced the composite primary endpoint of 30-day all-cause mortality or need for renal-replacement therapy, as shown in Figure 8 .

Short-term mortality in the SHOCK trial. The SHOCK trial, comparing early revascularization to standard medical therapy in patients with AMI complicated by CS, showed no significant difference in 30-day mortality between the two groups. AMI = acute myocardial infarction; CS = cardiogenic shock. Adapted from Hochman et al.

Rate of primary composite outcome occurrence in the CULPRIT SHOCK trial. The CULPRIT-SHOCK compared whether immediate multivessel strategy or culprit-vessel-only strategy was more effective in patients with multivessel coronary disease. Findings suggested culprit-lesion-only revascularization significantly reduced the composite primary endpoint of 30-day all-cause mortality or need for renal-replacement therapy. Adapted from Thiele et al.

Beyond immediate survival, survivorship outcomes were also documented in SHOCK trial survivors. Long-term assessments demonstrated that most patients who underwent emergency revascularization achieved acceptable functional and QoL outcomes. At 1 year, 87% were NYHA functional class I or II, and deterioration in functional status and QoL was less frequent compared with those initially managed medically (15% vs 34%). Therefore, while revascularization provides clear mortality benefit, it is also associated with improvements in long-term functional recovery and QoL.

Intra-aortic balloon pump: The first type of mechanical circulatory support device to be widely adopted in CS was the IABP, which supports cardiac function by inflating during diastole to improve coronary perfusion and deflating immediately before systole to reduce afterload. In a 2025 meta-analysis of two randomized trials (133 patients) with CS by HF, IABP did not significantly improve 60-day survival or bridge to heart replacement therapy (RD = 0.12, p = 0.096). However, in a subgroup analysis of patients classified as stage C or D by the Society for Cardiovascular Angiography and Interventions classification, IABP use was associated with significantly higher 60-day survival and successful bridge to heart replacement therapy (RD = 0.17, p = 0.04).

Consistent with these results, a 2019 study re-evaluating outcomes in 591 CS survivors 6 years after the IABP-SHOCK II randomized control trial, mortality remained comparable between IABP and control groups. Among survivors, functional recovery and QoL were also similar: 82% of patients in both groups were in NYHA class I or II, and there were no differences in EQ-5D or visual analogue scale QoL scores. Overall, although useful in immediate hemodynamic stabilization, current evidence for IABP shows few improvements in short-/long-term mortality, symptom burden, or QoL.

Microaxial flow pump (Impella): The Impella microaxial flow pump provides percutaneous left ventricular support by drawing blood from the left ventricle into the ascending aorta. Several different models are available, including the Impella 2.5, CP, 5.0, and 5.5, which differ in their peak flow capacity (2.5 to 5.5 L/min) and insertion methods . The Impella 2.5 and CP are inserted percutaneously through the femoral artery, whereas the Impella 5.0 and 5.5 require surgical insertion through the axillary or femoral artery. A 2024 meta-analysis of six randomized controlled trials compared Impella with standard medical therapy and IABP in AMI-CS. Impella use did not significantly reduce 30-day all-cause mortality but was associated with a reduction in 6-month mortality (OR 0.64; 95% CI 0.43 to 0.95; p = 0.03). However, the Impella was found to be associated with a greater complication burden, with higher rates of major bleeding, peripheral limb ischemia, and sepsis. Impella support also extends to the right heart with the Impella RP by drawing blood from the inferior vena cava to the pulmonary artery. In a 2025 retrospective cohort of 22 patients with CS treated by the Impella RP, the device was associated with improved hemodynamic parameters; however, in-hospital mortality remained high at 31.8%. Device-related complications were also common, including hemolysis (86.4%), transfusion requirement (63.6%), and need for inpatient hemodialysis (68.2%). Moreover, among device types, higher flow pumps appear to have better outcomes. In a 2024 analysis of 1,238 patients, the Impella 5.5 showed greater survival to explant than the 5.0 in AMI-CS (70.5% vs 56.8%).

Beyond mortality, recent data suggest that Impella support may also improve short-term QoL. In a 2025 study of patients with HF-related CS, scores on the Kansas City (QoL) Cardiomyopathy Questionnaire showed significant improvement in symptom frequency and QoL after 2 weeks of Impella. By improving cardiac output and alleviating fatigue and breathlessness, patients reported a noticeable improvement in overall well-being. Physical function also trended upward, although social limitations remained unchanged. Neurological recovery has likewise been documented in patients who transitioned to Impella after extracorporeal life support, where 59% achieved an acceptable cerebral performance category (1 to 2) and 64% achieved a normal modified Rankin Scale (0 to 3). Overall, current evidence suggests that Impella may provide gains in early mortality and QoL, but these benefits are associated with higher complication rates and limited data on long-term recovery.

Venoarterial extracorporeal membrane oxygenation: As the severity of CS progresses, VA-ECMO is the last escalation in mechanical support, offering hemodynamic relief by passing venous blood through an external oxygenator. However, despite its capacity to rapidly restore systemic perfusion, evidence has shown little mortality benefit. A 2024 review of four randomized trials in AMI-related CS demonstrated no reduction in 30-day mortality with VA-ECMO compared to standard therapy. This finding was confirmed by a 2023 meta-analysis that also revealed higher rates of major bleeding (25% vs 12%) and limb ischemia (11% vs 4%) among VA-ECMO recipients. The therapy is also resource-intensive, requiring specialized personnel, prolonged ICU stays, and complex postweaning management.

Long-term outcomes among survivors are also limited. In a 2021 54-month follow-up of 119 patients with pulmonary-embolism-related CS, mean EQ-5D-5L QoL scores were lower than population norms (0.7 ± 0.3 vs 0.9 ± 0.04; p <0.01), with 74% maintaining mobility, 65% daily independence, 33% returning to work, and 30% reporting anxiety or depression. Another 2025 5-year study of 428 cardiac and respiratory failure survivors post-VA-ECMO showed persistent decline in mobility (39%), daily activity (44%), and chronic pain (60%). A 2024 meta-analysis documenting neurological outcomes in CS patients post-ECMO found that, compared to conventional CPR, VA-ECMO increased the likelihood of midterm favorable neurologic recovery by 59% (RR 1.59, 95% CI 1.09 to 2.33, p = 0.02), a difference that was not significant at long-term follow-up (RR 1.47, 95% CI 0.89 to 2.43, p = 0.13).

Despite VA-ECMO’s ability to rapidly stabilize hemodynamics, the retrograde aortic flow it generates increases left ventricular afterload, leading to potential myocardial injury. The emerging strategy of left ventricle unloading counteracts this effect through the use of complementary mechanical support such as the Impella, IABP, or surgical venting. A 2025 meta-analysis of 9,858 patients reported a lower mortality and better neurologic recovery when using Impella with ECMO. Moreover, this strategy was found to be more effective when started early, within 2 hours of VA-ECMO initiation. Overall, VA-ECMO’s immediate hemodynamic support currently translates into few long-term mortality or QoL gains.

Ventricular assist devices: VADs can be categorized as temporary or durable and can support either the left or right ventricle. Temporary left VADs, such as the IABP, Impella, and VA-ECMO, are used for short-term stabilization. Temporary right VADs, such as the Impella RP, are used in short-term support for right-sided failure. In a 2025 analysis of 6,201 patients hospitalized with CS, temporary percutaneous right VADs were implemented in 2.4% of cases, most commonly the ProtekDuo (71%). The overall in-hospital mortality for patients receiving right VAD support was 54.6%, with comparable survival rates observed regardless of the device used.

In contrast, durable VADs are surgically implanted systems that provide long-term mechanical circulatory support. In a 2018 retrospective study of 43 patients with CS, durable left VAD implantation was associated with a 6-month survival of 82.7% and a 12-month survival of 73.9%, with an operative mortality of 13.9%. More observational data from 2024 involving 560 advanced HF patients with durable left VADs showed 5-year gains in functional capacity and QoL, highlighting their potential benefit on long-term outcomes as well. Specifically, the HeartMate 3, which uses a magnetically suspended centrifugal-flow design, is the most widely used left VAD in the United States. Compared with its mechanically supported axial-flow predecessor, the HeartMate II, the HeartMate 3’s frictionless magnetic design reduces risk for pump thrombosis, hemolysis, and stroke. The 2019 MOMENTUM 3 trial compared outcomes in 1028 HF patients with Heartmate 3 versus Heartmate 2. After 2 years, survival free of stroke and device replacement was significantly lower in the Heartmate 3 group (76.9%) than in the Heartmate 2 group (64.8%) (RR 0.84, 95% CI 0.78 to 0.91; p <0.001). This survival benefit was found to persist at 5-year follow-up as well. However, there was no significant difference in QoL and functional status between the groups, with both showing improvements.

Heart transplantation is a last-line option for refractory CS. It is reserved for patients with irreversible HF who remain dependent on inotropes or mechanical support despite optimal therapy and without major contraindications. Contemporary data on heart transplantation in CS are limited, but older cohorts demonstrated substantial reductions in mortality among transplanted patients. Available data show 1-year survival rates exceeding 90% among cardiac transplant recipients overall. Subsequent investigations have examined the optimal timing and strategy of transplantation, comparing left VAD bridging with direct procedures. A 2025 study comparing cardiac transplantation in HF patients previously bridged with a left VAD to direct transplantation reported similar early and long-term outcomes. One-year survival was 89.3% for bridge-to-transplant and 85.7% for direct-to-transplant recipients (p = 0.745), with 7-year survival of 80.8% and 77.1%, respectively (p = 0.840). These findings suggest that for patients with refractory CS, heart transplantation, whether performed directly or following left VAD bridging, offers good long-term survival.

The underlying etiology of CS strongly influences its management. AMI-CS results from sudden myocardial injury due to ischemia, whereas HF-CS develops more gradually from progressive pump failure. As such, in AMI-CS, the primary goal is a rapid restoration of perfusion through early revascularization and antithrombotic therapy, combined with inotropes, vasodilators, and temporary mechanical circulatory support stabilization when needed. However, randomized trial data have not demonstrated a mortality benefit with routine IABP or VA-ECMO use in AMI-CS, whereas Impella has shown potential survival benefit in certain patients. Observational data further suggest that earlier Impella implantation before percutaneous coronary intervention is associated with improved short- and midterm survival outcomes compared with delayed implantation during or after revascularization. As such, the 2025 American Heart Association guideline updates recommend against the routine use of IABP and VA-ECMO in AMI-CS, while supporting the selective use of Impella in patients with severe or refractory shock. This may reflect adverse hemodynamic effects of isolated VA-ECMO, as left ventricular distension increases wall stress and filling pressures, thereby exacerbating myocardial ischemia. Accordingly, a 2025 systematic review and meta-analysis demonstrated that VA-ECMO combined with Impella was associated with reduced mortality in AMI-CS cohorts, highlighting the potential benefit of left ventricular unloading for these patients.

In contrast, HF-CS management prioritizes hemodynamic control through prolonged the use of inotropes and vasodilators, with mechanical circulatory support more often employed as a bridge to long-term strategies such as durable VAD implantation or transplantation. ^, Consistent with this approach, 2026 registry data indicate that stepwise escalation from IABP to more advanced mechanical circulatory support does not increase mortality in HF-CS but is associated with higher mortality in AMI-CS. These differing approaches reflect the acute, reversible nature of AMI-CS compared to the chronic, progressive course of HF-CS.

CICU liberation bundle: The CICU liberation bundle, modeled on the ABCDEF framework shown in Figure 9 , was introduced as a central strategy to improve recovery in cardiac critical care by promoting light sedation, early mobilization, delirium monitoring, and family engagement. ^, In general ICU populations, the use of the ABCDEF bundle has been associated with substantial short-term benefits. A 2019 cohort study of more than 15,000 adults linked higher bundle compliance with a reduced risk of hospital death and reduced odds of mechanical ventilation, coma, delirium, physical restraint use, ICU readmission, and nonhome discharge. Beyond acute recovery, a 2023 systematic review and meta-analysis of 18 studies showed that general ICU patients receiving ABCDEF-based care achieved earlier mobility milestones, higher physical-function scores, and greater rates of discharge without restrictions. Additionally, QoL assessments showed higher physical and mental composite scores at 90 days with ABCDEF-based care. Despite limited evidence in CS, even partial CICU bundle use, including early VA-ECMO mobilization, appears to enhance weaning and functional recovery. The 2025 AHA CS guidelines recommend incorporating CICU liberation bundle protocols into standard care to optimize post-ICU survivorship.

The intensive care unit liberation bundle. The CICU liberation bundle was introduced as a strategy to improve recovery in cardiac critical care by following the ABCDEF acronym: assessment of pain, both spontaneous awakening and breathing trials, carefully choosing analgesia and sedation, delirium prevention, early mobility, family engagement. Adapted from Ely.

Shock teams: Multidisciplinary shock teams have been developed for the management of CS, aiming to improve communication, expedite decision-making, and standardize care across cardiac intensive care units. A multicenter observational study of 6,800 CICU admissions found that the presence of a shock team was associated with significantly lower in-hospital mortality in CS (23% vs 29%, p = 0.025). Shock-team centers also showed greater use of pulmonary-artery catheters, more frequent use of mechanical circulatory support, and less reliance on IABPs, reflecting more evidence-based management. By coordinating rapid escalation and de-escalation of therapies, shock teams enable timely support adjustments and smoother care transitions. While these results demonstrate short-term survival benefits, no studies to date have evaluated long-term survivorship, representing a key gap for future research.

Patient and family engagement: A 2022 American Heart Association Scientific Statement recommends structured patient and family integration in the CICU. This implies directly including patients and relatives in CS care. Opportunities for this include clear communication, involvement in care planning and rounds, participation in mobilization and delirium-prevention, and education to support informed decision-making. Evidence supporting this approach is growing. In one study of ICU survivors, 85% of patients reported active engagement in their care, which was associated with feeling more informed and satisfied with treatment. Similar benefits have been observed when families are actively involved. In a 2025 CICU cohort of 104 patients, family engagement often included communication (100%), active family presence (36.59%), and direct contribution to care (35.57%). Such involvement was associated with a lower 30-day readmission rate (5% vs 16%, p = 0.05). Another 2021 family participation program in a cardiovascular surgery ICU involving 56 family members significantly improved their care satisfaction and anxiety. Although direct evidence in CS populations remains limited, these findings suggest that structured family and patient engagement in CICU care may enhance both patient and family outcomes.

Postdischarge survivorship: Following hospital discharge, CS survivors require structured, multidisciplinary follow-up to address the high burden of physical, cognitive, psychological, and QoL sequelae, as shown in Figure 10 . However, survivorship data are limited, with few studies extending beyond 1 year and most lacking functional or QoL assessments. In a 2023 cohort of 9,789 CS patients, 42% of survivors required a higher level of care than before admission, 47.5% were readmitted within 1 year, and 15.3% died within the first year after discharge. These findings highlight the persistent vulnerability and poor survivorship of CS patients despite initial stabilization. Additionally, follow-up from the SHOCK and IABP-SHOCK II trials showed reduced 1-year QoL, with 20% to 30% of survivors noting impairments in daily functioning, physical capacity, or mental health. Survivorship also differs by sex, with female patients being associated with worse outcomes. In a 2023 study of patients with 3202 AM I-CS, female survivors had higher mortality rates and more major adverse cardiac events in-hospital, and at 1-month and 3-year follow-ups. Similarly, CS etiology significantly affects survivorship. In a 2025 cohort of 378 people, HF-CS patients had higher 31-day to 2-year mortality rates compared to AMI-CS patients (45% vs 22%, p = 0.02).

Longitudinal survivorship in cardiogenic shock. Survivorship spans beyond acute mortality. CS survivors require structured, multidisciplinary follow-up to help with physical, cognitive, and psychological recovery to improve their QoL. CS = cardiogenic shock; QoL = quality of life. Adapted from Hall et al.

While it is well established that long-term outcomes after CS are unfavorable, few studies detail the specific functional and cognitive deficits after hospitalization. Existing evidence, however, consistently highlights a high frequency of mental health disorders in this population. In a 2024 cohort of 7,812 CS survivors, the incidence of mental health diagnoses after AMI-CS was 109.6 per 1,000 person-years. While immediate mortality after CS has improved, many patients continue to experience significantly reduced survivorship outcomes, emphasizing the need for long-term follow-up.

Postdischarge care and rehabilitation: Comprehensive postdischarge cardiac recovery programs should integrate physical activity, diet changes, risk factor modification, psychological support, patient and family education, and social assistance. These interventions are best organized through a multidisciplinary team, consisting of cardiologists, nurses, exercise physiologists, dietitians, and psychologists. Evidence consistently shows that participation in structured cardiac rehabilitation after discharge improves survival. In a 2020 cohort of 26,171 patients with cardiovascular disease, cardiac rehabilitation was associated with a 32% reduction in all-cause mortality. ^, Importantly, its benefit appears to be dose dependent. In a 2020 observational study of 9,981 participants, durations of cardiac rehabilitation over 150 days were associated with the greatest decreases in both mortality and major adverse cardiovascular events. Cardiac rehabilitation is particularly important given the high prevalence of frailty among CICU patients, estimated in 30% of those with advanced cardiovascular disease, and its association with prolonged recovery and increased mortality. Structured exercise, nutritional support, and multidisciplinary rehabilitation improve physical function and can reverse frailty.