Key result
Only ~13% of cardiogenic shock survivors achieve 4-pillar medical therapy at 1 year.
Why the study?
Improved acute care for cardiogenic shock has increased survivorship and long-term functional disability, but data on long-term survival and follow-up implementation of 4-pillar guideline-directed optimized medical therapy remain limited.
Cohort (n=687)
Yes
In a contemporary cohort of cardiogenic shock hospital survivors, 1-year mortality remains high at 45% and 4-pillar guideline-directed medical therapy is substantially underutilized, achieved in only 13% of patients at 1 year.
High mortality and low four-pillar therapy rates after cardiogenic shock discharge warrant closer monitoring; leaves open prospective studies on implementation barriers.
Background Survival to hospital discharge in patients with cardiogenic shock (CS) marks the beginning of a long journey toward cardiac and functional recovery. Multidimensional disorders and long-term functional disability are increasing, contributing to a growing assistance burden due to improved acute care leading to increased survivorship. However, limited data exist on long-term survival and the implementation of 4-pillar guideline-directed optimized medical therapy (OMT) prescription at follow-up. To address this gap and promote post-discharge medical optimization and functional recovery, we developed the ENIGMA-shock project (framEwork for aN InteGrated assessMent of cArdiac rehabilitation programmes in patients acutely managed for cardiogenic shock) with the aim of improving the management of post-critical syndrome in CS fostering quality improvement strategies starting from patient admission. Purpose To evaluate the 1-year status of CS survivors treated at 13 Italian hub centers experienced in the care of CS patients and a high intensity cardiac rehabilitation, using a hierarchical composite outcome of survival and OMT administration. Methods We analyzed 687 patients from the ALT SHOCK - ENIGMA registry who survived to hospital discharge. The primary 1-year endpoint was assessed using a proportional odds ordinal logistic regression model. The model was adjusted for age, sex, etiology, diabetes, renal insufficiency, SCAI stage, lactate, ejection fraction, and creatinine. The outcome Y was ranked hierarchically from worst to best status: death; alive on 0 drugs; alive on 1 drug; alive on 2 drugs; alive on 3 drugs and alive on OMT (4 drugs). This method predicts the probability of having at least a given number of therapeutic pillars. A nomogram is reported to visually represent the contribution of baseline variables to the probability of reaching a specific ordinal clinical status. Results At 1-year of follow-up, an estimated 45% of patients were dead; 5% of patients were alive without drugs, 14% with one, 16 % with two, 7% with three, and 13% with OMT (Fig 1). Older Age, higher creatinine, lower LVEF, higher SCAI Stage were independent predictor of failure to achieve OMT (Fig. 2). Conclusion In a contemporary cohort of CS patients, 1-year mortality is still high and occurs mostly in the first six-months after hospital discharge. Among survivors, OMT remains underutilized. Future analyses should clarify the determinants of OMT underuse and limited up-titration (e.g., in-hospital complications, clinical status at hospital discharge, tolerability, and adherence to follow-up). To truly redefine the metrics of the treatment in CS, a multidisciplinary alliance has to be promoted since the patient’s admission, involving all the stakeholders in a new early integrated care perspective.Fig 1Fig 2
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Guarnieri et al. (2026) conducted a cohort in Cardiogenic shock (n=687). 4-pillar guideline-directed optimized medical therapy (OMT) vs. 0, 1, 2, or 3 drugs was evaluated on Hierarchical composite outcome of 1-year survival and optimized medical therapy (OMT) administration (ranked from death to alive on 0, 1, 2, 3, or 4 drugs). Four-pillar optimized medical therapy was achieved in 13% of cardiogenic shock survivors at 1 year, while 45% died and 42% received 0 to 3 drugs.
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