The pressure is on: balancing cardio-pulmonary haemodynamic interactions in cardiogenic shock

Welcome to the November issue of the European Heart Journal—Acute Cardiovascular Care (EHJ-ACVC), with a focus on mechanical ventilation in acute cardiovascular care. Since the life-saving potential of mechanical ventilation became evident during the poliomyelitis epidemics of the 1950s, it has evolved an integral therapy in (cardiac) intensive care.1,2 Yet its increasing sophistication reminds us that ventilation is not simply respiratory support. In the critically ill cardiovascular patient, changes in intrathoracic pressure affect venous return, ventricular loading conditions, pulmonary vascular resistance, and cardiac output. PEEP may improve oxygenation while altering haemodynamics; intubation may rescue a patient from respiratory failure yet precipitate cardiovascular collapse; and liberation from ventilation may itself constitute a cardiovascular stress test. These interactions are particularly important in cardiogenic shock. In a nationwide Danish cohort previously published in EHJ-ACVC, approximately two thirds of patients with cardiogenic shock received invasive mechanical ventilation in 2017, despite a decline in its use over time, while the use of non-invasive ventilation increased.3