Kriti Puri, MBBS, is a pediatric cardiologist and cardiac intensive care physician with Texas Children’s Hospital and an assistant professor at the Baylor College of Medicine.

Kriti Puri, MBBS

A new proposed definition of cardiogenic shock in pediatric patients may pave the way for improved intervention and outcomes for this notoriously underrepresented condition.

Recognizing, Diagnosing, and Managing Pediatric Cardiogenic Shock

Despite being heavily studied in adult patients, there is still very little evidence regarding cardiogenic shock in pediatric patients. A 2023 study published in the Journal of the American College of Cardiology investigated the incidence, epidemiology, and outcomes of cardiogenic shock in pediatric patients – this study found that the disease occurs in roughly 26% of pediatric hospitalizations for 

 and is independently associated with hospital mortality.

To address this issue, Kriti Puri, MBBS, a pediatric cardiologist and cardiac intensive care physician with Texas Children’s Hospital and an assistant professor at the Baylor College of Medicine, and colleagues proposed a new definition for the disease in pediatric patients, as well as providing suggestions on each step of the treatment process for this underrepresented condition.

“The definition that we propose in this statement basically just encourages clinicians to think of the heart, especially if they have a patient that is in undifferentiated shock without prior known cardiac history,” Puri told 

 in an exclusive interview. “And then if there is that suspected cardiac dysfunction, and they have evidence of hypoperfusion, clinicians should really consider it as cardiogenic shock unless proven otherwise and utilize those principles of management.”

Puri and colleagues searched the limited existing literature regarding pediatric cardiogenic shock, collating existing data into the current document. The team noted that this literature is intrinsically limited by small sample sizes and selection bias. Larger cohort studies typically examined patients with ADHF – these documents may not always distinguish between patients with early or beginning cardiogenic shock and those with more extreme severity, potentially leading to invasive circulatory or respiratory support.

From the existing data, Puri and colleagues developed a classification system for cardiogenic shock, constructed similarly to the Society of Cardiovascular Angiography and Imaging (SCAI) classification for adults. In the present system, patients with known or suspected cardiac dysfunction are considered at risk, while those with evidence of derangement of vital signs or hemodynamics from baseline and symptoms have beginning cardiogenic shock. Patients with evidence of hypoperfusion, with or without hypotension, are in classic cardiogenic shock, while those who have received an intervention but are continuing to worsen are in stage D, or deteriorating, cardiogenic shock. Patients presenting or deteriorating to circulatory collapse requiring resuscitation are in stage E.

Puri and colleagues also established a diagnostic process for cardiogenic shock, including a physical examination for congestion or low cardiac output. The team recommends chest radiographs and electrocardiograms, which provide insight rapidly into the cause of cardiogenic shock. Additionally, near-infrared spectroscopy, when possible, may be useful in evaluating regional capillary-venous hemoglobin saturation.

In regard to monitoring, Puri and colleagues recommend the establishment of durable/central venous access and the placement of an arterial line to monitor adequacy of cardiac output, tissue perfusion, and arterial oxygen content. Additionally, the team suggests central venous oxygen saturation sampling and NIRS.

The authors note that management of pediatric cardiogenic shock should focus on hemodynamic optimization, aiming to restore adequate oxygen delivery to peripheral tissues while minimizing oxygen use. They also point out that initial management often occurs in an emergency department or another noncardiac intensive care setting – to this end, Puri and colleagues indicate that therapy should largely focus on facilitating transfer to a higher level of care.

Ultimately, despite the depth and specificity of the document, Puri and colleagues note the need for further research to further tailor these recommendations. Locating biomarkers of cardiogenic shock, as well as delineating phenotypes and optimizing interventions, are critical next steps for the refinement of this preliminary definition.

“The proposed definition and classification system, while they are new and while we have adapted them from data that have previously shown that they are valid, there is probably room for further finessing,” Puri said. “We are the first to admit that pediatrics still needs a lot of studies on the true phenotypes of pediatric cardiogenic shock, the impact of inflammation, and the impact of socioeconomic determinants of health as a risk modifier. These are the aspects that still need more data.”

Editors’ Note: Puri reports no relevant disclosures.

Puri K, Allen K, Jentzer J, et al. Surviving pediatric cardiogenic shock: Clinical approach, improving outcomes, and future directions: A scientific statement from the American Heart Association. 

Puri K, Jentzer JC, Spinner JA, et al. Clinical presentation, classification, and outcomes of cardiogenic shock in children. Journal of the American College of Cardiology. 2024;83(5):595-608. 

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Kriti Puri, MBBS, and colleagues have developed a preliminary definition and treatment strategy for this underrepresented disease.

Kriti Puri, MBBS

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