Node-Based Framework for Regionalized Cardiogenic Shock Systems of Care: Evidence, Design, and Future Directions

Cardiogenic shock (CS) is a cardiovascular emergency with short-term mortality ranging from 30% to 40% despite an expanding therapeutic armamentarium. Structured systems of care have transformed outcomes in ST-segment-elevation myocardial infarction, stroke, and out-of-hospital cardiac arrest through tiered hospital designations, standardized protocols, and regionalized networks, yet no analogous framework exists for CS. CS differs from these conditions in ways that complicate direct application of existing models: the appropriate intervention varies by cause, hemodynamic phenotype, and shock severity; the therapeutic trajectory is iterative and uncertain rather than binary and time-fixed; prehospital identification is rarely feasible; and the exit strategy, encompassing myocardial recovery, durable mechanical support, transplantation, or palliation, has no parallel in other cardiovascular emergencies. Observational data suggest an association between structured multidisciplinary care, regionalized networks, and more consistent care delivery though causal relationships remain unestablished, and no standardized national framework for CS center designation yet exists. We propose that CS systems of care should be organized around a node-based model in which each hospital tier has a defined role, transfer is guided by physiological trajectory and exit strategy candidacy rather than geography, and system performance is evaluated by metrics of timing, outcomes, and equity. The American Heart Association Cardiogenic Shock Registry, designed to enroll consecutive patients across all etiologies and severity levels, represents the natural infrastructure around which this framework can be constructed. Realizing this vision will require dedicated registries, implementation research, and a definition of success that extends beyond in-hospital survival to encompass recovery, function, and equitable access to care.