ABSTRACT
Cardiogenic shock (CS) remains a high-mortality condition that demands rapid diagnosis, coordinated multidisciplinary management, and timely initiation of mechanical circulatory support. As more institutions implement dedicated CS teams, substantial heterogeneity has emerged in how these teams are structured, activated, and sustained. To better characterize this variability and begin defining the components of an optimal CS team, the Society of Critical Care Cardiology (SoCCC), in partnership with the Society for Cardiovascular Angiography and Interventions (SCAI), convened the Inaugural Cardiogenic Shock Teams Think Tank. Held on October 17, 2024, as a preconference program to SCAI SHOCK 2024 in Washington, DC, the meeting brought together national leaders in CS care, mechanical circulatory support, and resuscitation to identify shared challenges and propose practical solutions.
This manuscript summarizes key insights from this inaugural Think Tank, which represents the first in an ongoing series of collaborative efforts aimed at informing the standardization and optimization of CS teams nationwide. Specifically, we review the ideal composition and core competencies of a CS team; the rationale and emerging evidence supporting dedicated team-based CS care; activation algorithms and operational workflows; and common barriers to establishing and sustaining such teams. We also outline future directions and opportunities to strengthen collaborative infrastructure, refine clinical pathways, and enhance the reliability, responsiveness, and effectiveness of cardiogenic shock teams across diverse healthcare settings.
Background
Cardiogenic shock (CS) continues to be associated with high in-hospital morbidity and mortality. Moreover, afflicted patients are increasingly medically complex, presenting in many cases with multiorgan system dysfunction. With the more frequent use of surgical and percutaneous coronary revascularization, mechanical circulatory support (MCS), and advanced therapies such as orthotopic heart transplantation and durable left ventricular assist devices, shock care now requires multidisciplinary involvement and coordinated management. CS teams have become increasingly prevalent, particularly within tertiary and quaternary care centers, and their role in identifying and managing the patient with CS is now endorsed by the American Heart Association as well as the 2022 AHA/ACC/HFSA guidelines for heart failure and 2025 ACC Concise Clinical Guidance on CS. ,,,,, While a multidisciplinary approach to CS has gained more widespread acceptance, anecdotally significant variability remains in the composition, protocolized processes, and daily operations of these teams. This heterogeneity may impact outcomes and could help explain why some centers have excelled in implementing CS teams, while others have struggled to establish and maintain effective models. Although observational data suggest that CS teams may improve outcomes for patients, little evidence supporting the optimal composition and functioning of these teams is available from which to help guide their assembly, implementation, and daily operations.
The presence of significant variability in CS teams and the need to define best practices has been underscored in a recent manuscript, in which authors advocated for a dedicated, multidisciplinary “think tank” to help address the aforementioned concerns. On October 17, 2024, a Cardiogenic Shock Teams Think Tank was convened– developed and executed as a partnership between the Society of Critical Care Cardiology (SoCCC) and the Society for Cardiovascular Angiography and Interventions (SCAI). Held as a preconference meeting in conjunction with SCAI Shock 2024 in Washington, DC, this collaborative effort brought together leading experts in CS care, MCS, and resuscitation to explore existing challenges and to propose potential solutions. This paper serves as a summary of this inaugural meeting and what intends to be the first of a series of collaborative discussions aimed at informing the standardization and optimization of CS teams nationwide. Specifically, we will examine the ideal composition for a CS team; the rationale for and evidence to support CS teams; algorithms and protocols for CS team activation; challenges and barriers in establishing and maintaining a CS team; and will explore future directions and opportunities for leveraging these teams.
What is the ideal composition for a cardiogenic shock team?
While there is indeed heterogeneity in the composition of CS teams, most well-established programs share and leverage a core group of key subspecialty participants: Critical Care Medicine or Critical Care Cardiology, Interventional Cardiology, Advanced Heart Failure and Transplant Cardiology, and Cardiothoracic Surgery. These 4 disciplines frequently form the foundation of CS teams, with additional specialties incorporated based upon institutional resources, needs, and culture. Each discipline brings a unique perspective and specialized skill set to the management of patients with CS, contributing therefore to a multidisciplinary, synergistic, and comprehensive approach to care.
In most centers, the origins of the CS team can be traced back to the increasing use of temporary MCS (tMCS) and increased complexity and comorbidity of CS patients. Initially, the team responsible for placing the device naturally assumed the role for what we now recognize as the CS team. However, as patient management evolved with newer device therapies and advanced treatment options—including transcatheter valve interventions, complex ablation procedures, durable MCS and cardiac transplantation—the decision-making process became more complicated, requiring broader discussions and multiple subspecialty perspectives. With increasing complexity and the ability to provide more therapeutic options, hospitalizations also grew longer, further underscoring the need for coordinated care. While in the past, each consulted specialist might have weighed in serially or in parallel, the development of CS teams transformed these interactions into more collaborative, structured, and uniform conversations. In many institutions, the formal identification of a core CS team ultimately emerged from this shift toward multidisciplinary collaboration.
How have these specialists been uniquely leveraged? The critical care cardiologist or general critical care physician commonly serves as the quarterback for the team, coordinating care and overseeing the day-to-day management of patients with CS. The cardiac surgeon routinely contributes expertise for surgically reversible causes of CS– such as acute valvulopathies or septal defects– assesses surgical candidacy, and in some centers deploys and manages Impella 5.5 and veno-arterial extracorporeal membrane oxygenation (ECMO). Interventional cardiologists will offer percutaneous interventions for reversible etiologies including acute ischemia or valvular injury, and can provide a range of tMCS options, including peripheral ECMO at some centers. Finally, the advanced heart failure cardiologist often plays the crucial role of evaluating patients for heart replacement therapies, including cardiac transplantation and durable left ventricular assist devices, as well as options to enhance myocardial recovery. However, these roles may vary from team to team and from institution to institution based upon culture and expertise.
While the core CS team in most institutions consists of these 4 subspecialties, the complexity of CS patients has led many centers to expand their multidisciplinary teams to include additional experts. One of the earliest adaptations, particularly in centers serving as hubs for smaller spoke centers that either consult for local CS management or transfer patients for management, was the integration of advanced practice providers (APPs). APPs often serve as the operational cornerstone of the CS team, playing a pivotal role in bedside care and facilitating care coordination. They ensure continuity by tracking patients across the spectrum of care: following up on consults, facilitating timely and safe inter-facility transfers, and helping to implement care plans consistently across shifts and teams. Unlike many physicians, who often balance their shock team responsibilities alongside other primary clinical duties, APPs are frequently recruited into dedicated roles, allowing them to provide sustained focus and stability. In many institutions, APPs also contribute to protocol development, data collection, quality improvement efforts, and education, making them indispensable to both the day-to-day functioning and the strategic advancement of CS programs.
Additional specialties that have been integrated into CS teams at various institutions include pharmacy, palliative care, social work and case management, physical therapy, occupational therapy, respiratory therapy. Notably, 1 critical group that has often been overlooked include emergency medical services (EMS) and the emergency department (ED) physicians. These providers are frequently the first points of contact for patients with CS and play crucial roles in triaging and transporting these patients to higher levels of care, making their integration into the CS team a crucial topic for further discussion ( Figure 1 ). Early intervention at this stage presents a key opportunity to enhance and expedite disease identification, improve clinical phenotyping, attenuate the progression of shock, facilitate appropriate triage, and improve patient outcomes.
The evolving structure of cardiogenic shock (CS) teams— from roots to branches. There is ongoing evolution in the composition of CS teams, which differ across institutions. While most share common roots in interventional cardiology, critical care, heart failure, and cardiothoracic surgery, newer teams have expanded to include broader disciplines, and continued growth is needed to incorporate EMS, Emergency Medicine, and hospital administration.
Suggestion for clinical practice: Institutions should tailor team composition based upon available resources, personnel, and patient population, and ensure inclusion and collaboration across multiple disciplines in order to promote seamless, rapid clinical decision-making.
Why should institutions consider a CS team?
During the think tank discussion, several reasons were emphasized for the necessity of CS teams in patient care. Some focused on optimizing patient management, while others highlighted the need to support providers in making complex decisions with long-term repercussions for these critically ill patients, as well as the potential financial benefits to the health system and cost-effectiveness associated with structured CS teams.
Patient outcomes and process metrics
A common narrative among participants who practiced both before and after the establishment of a CS team was the crucial role these teams played in expediting, standardizing, and streamlining care for patients. Previously, primary providers would sequentially consult 1 subspecialty—such as interventional cardiology—exhaust its available options, and then move on to the next subspecialty, repeating this process until they either found a specialty willing to intervene or 1 that assumed patient care. This approach was time-consuming, led to delays, and resulted in fragmented care, and significant undesired care variability within and between institutions. CS teams unified these previously disjointed discussions into a single, coordinated setting, expediting decision-making and care delivery while also fostering direct communication among subspecialists ( Figure 2 ). Beyond shock care, this increased collaboration and esprit de corps generated important “halo effects,” strengthening multidisciplinary relationships, enhancing trust, and creating positive spill-over effects that benefited a wide array of cardiovascular programs.
Streamlining care through multidisciplinary cardiogenic shock teams. CS teams replace fragmented, sequential specialty consultations with a unified, real-time multidisciplinary approach. By bringing all key stakeholders together at once, they eliminate the “game of telephone,” shorten decision times, and ensure that all therapeutic options are considered simultaneously.
In addition to this, most centers had CS management protocols in place even before establishing dedicated CS teams. However, the extent to which these protocols were implemented often depended on the individual providers caring for the patient. One key factor driving the formation of CS teams was the need to ensure consistent adherence to agreed-upon protocols, promoting standardized and structured care rather than succumbing to provider-dependent variability. Anecdotally, multidisciplinary discussions and diverse perspectives within the team were seen as effective in reducing protocol deviations and promoting adherence to “best practices”- especially given that CS patients are so complex that no single protocol can fully capture the nuances involved in the care of any individual patient. Moreover, in many institutions with well-established CS teams, structured follow-up protocols such a debriefing sessions or after action reviews, and morbidity and mortality conferences were implemented as part of quality improvement efforts. These processes not only identified protocol deviations but also provided forums to analyze care delivery, address inconsistencies and refine processes and protocols over time.
Clinician support and mitigation of burnout
Decisions impacting the care of patients with CS are not only highly complex but can also be emotionally challenging. While the focus on CS is often its high mortality rate, even those who survive can face substantial morbidity and arduous mental and physical convalescence. Many patients may be unable to make informed decisions about their care, despite the potential for long-term and sometimes severe consequences. Although their decision-making surrogates are frequently consulted and involved, providers are often left to navigate difficult clinical choices in an area with limited data to guide practice. Additionally, these decisions can consist of ethical dilemmas, adding another layer of complexity to an already challenging process. Many in the think tank emphasized that making these types of decisions unilaterally on behalf of a patient can be burdensome in a myriad of ways. First, it carries a significant emotional weight—especially when outcomes are unfavorable or result in death—leaving the individual who made the decision to carry that responsibility alone, often leading to self-doubt. Second, it can create space for retrospective criticism, where others may question or suggest they would have chosen differently. Third, it may foster indecision or decision paralysis, where decisions are made passively rather than actively and intentionally. In the care of patients with CS this mental and emotional burden of making complex decisions in isolation was identified as a significant contributor to physician burnout. By making these complex decisions as a team, the emotional burden of difficult outcomes can be shared, and collective decision-making may help protect individual providers from undue scrutiny, ensuring that choices are made through structured, multidisciplinary discussions rather than resting on a single person’s judgment.
Financial incentives and cost-effectiveness for health systems
A strong case was made for the potential financial benefits of using CS teams in the care of patients with refractory CS. A recent publication by Taleb et al. demonstrated that patients managed by CS teams had significantly better outcomes at both hospital discharge and 1 year postdischarge, despite being sicker at baseline. On average, managing patients with a CS team costs $13,824 more per patient than standard care without a dedicated team. However, this additional investment led to better outcomes: the cost to save 1 additional life at hospital discharge was $102,088, while the cost to ensure 1 more survivor at 1 year was $96,152. Moreover, when considering quality-adjusted life years (QALY)—which accounts for both survival and quality of life—the cost per QALY gained was $127,862. These figures suggest that CS teams may provide a cost-effective approach to managing critically ill patients based on the commonly accepted cost-effectiveness thresholds in the U.S. (typically around $100,000–$150,000 per QALY), thereby justifying the higher upfront costs.
To this end, one of the participating hospital administrators emphasized that hospital leadership should, at a minimum, be peripherally involved in CS teams—particularly during case reviews—to witness firsthand their impact on both patient care and financial outcomes ( Figure 1 ). This involvement can help ensure the long-term sustainability of CS teams and was highlighted as valuable advice, especially for institutions that have historically struggled to establish and maintain such teams.
Suggestion for clinical practice: Engage hospital administrators early in the establishment of CS teams and recognize the broader role these teams can play in reducing clinician burnout and supporting complex decision-making.
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