Hemodynamic monitoring in AHF and cardiogenic shock should rely on individualized, multimodal and dynamic integration of clinical examination, biomarkers, echocardiography and invasive monitoring, with echocardiography as the cornerstone and invasive monitoring reserved for selected high-risk patients with persistent or complex shock.
Key Findings
Background
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.
The syndrome extends beyond simple pump failure to encompass multiple pathophysiological processes.
Systemic inflammation and vasoplegia are identified as components of the cardiogenic shock syndrome alongside impaired cardiac output.
Multiorgan dysfunction is recognized as part of the syndrome's clinical picture.
Results
Recent studies have emphasized phenotype-based approaches for both diagnosis and treatment of cardiogenic shock.
Machine learning-derived phenotypes have further identified cardiorenal and cardiometabolic profiles.
These machine learning-derived phenotypes are associated with distinct prognostic implications.
Results
Critical care echocardiography has a central role for rapid diagnosis and serial reassessment in AHF and cardiogenic shock.
Echocardiography is described as the cornerstone of bedside assessment.
Its role includes both initial rapid diagnosis and ongoing serial reassessment of the patient's condition.
Echocardiography is positioned as a primary monitoring tool before consideration of invasive approaches.
Results
Transpulmonary thermodilution and pulmonary artery catheterization provide complementary information to echocardiography in refractory or complex cases.
These invasive monitoring modalities are positioned as adjuncts rather than replacements for echocardiography.
Their use is indicated specifically in refractory or complex cases.
Invasive monitoring should be reserved for selected high-risk patients with persistent or complex shock.
Conclusions
The main goals of hemodynamic monitoring in AHF and cardiogenic shock are to define the underlying phenotype, assess congestion and tissue hypoperfusion, and evaluate treatment response.
A physiology-driven framework is advocated for advanced hemodynamic monitoring.
The approach is described as individualized, multimodal, and dynamic.
Integration of clinical examination, biomarkers, echocardiography, and invasive monitoring is recommended.
Assessment of both congestion and tissue hypoperfusion are highlighted as key monitoring targets.
What This Means
This review paper provides a framework for monitoring the heart and circulation in patients experiencing acute heart failure or cardiogenic shock — a life-threatening condition where the heart cannot pump enough blood to meet the body's needs. The authors emphasize that cardiogenic shock is not a single, uniform condition but rather a complex syndrome that can involve inflammation, blood vessel dysfunction, poor oxygen delivery to tissues, and failure of multiple organs. This heterogeneity means that a one-size-fits-all monitoring approach is inadequate.
The paper highlights that bedside ultrasound of the heart (echocardiography) should be the primary tool for assessing these patients, allowing rapid diagnosis and repeated check-ins as the patient's condition evolves. More invasive monitoring methods — such as placing specialized catheters in the heart's blood vessels — are recommended only for the most complex or treatment-resistant cases. Emerging approaches using machine learning have identified distinct patient 'profiles,' including those with predominant kidney involvement or metabolic abnormalities, each carrying different risks and potentially requiring different treatment strategies.
This research suggests that the best approach to monitoring critically ill heart failure patients involves combining multiple information sources — physical examination, blood tests, heart ultrasound, and sometimes invasive measurements — in a way that is tailored to each individual patient. The goal is to understand what subtype of shock the patient has, whether they have fluid overload or inadequate blood flow to organs, and whether treatments are working. This personalized, physiology-based strategy may help clinicians make better decisions and potentially improve outcomes for these high-risk patients.
Messina A, Jozwiak M, Monnet X. (2026). Advanced hemodynamic monitoring of the patient with acute heart failure and cardiogenic shock.. Current opinion in critical care. https://doi.org/10.1097/MCC.0000000000001420