{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T17:58:45Z","timestamp":1790618325777,"version":"4.1.0"},"reference-count":47,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2026,9,26]],"date-time":"2026-09-26T00:00:00Z","timestamp":1790380800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Cardiogenic shock (CS) remains a heterogeneous syndrome with persistently high mortality across acute myocardial infarction, decompensated heart failure, and post-cardiotomy states. Blood pressure, the most commonly used marker of hemodynamic status, is the product of cardiac output and systemic vascular resistance and can be preserved by compensatory vasoconstriction even as flow and tissue perfusion deteriorate. This review examines the evidence for measuring flow-derived hemodynamic parameters and biomarkers of hypoperfusion, rather than relying on pressure alone, to risk-stratify and inform therapy in CS. We propose a practical framework that distinguishes blood pressure targets, measured native flow, device-generated flow, and perfusion biomarkers, and that separates prognostic association from demonstrated treatment-guiding utility, since these are frequently conflated in the existing literature. We summarize data on pulmonary artery catheter-derived cardiac output and cardiac index, cardiac power output and index, the pulmonary artery pulsatility index, transpulmonary thermodilution and other advanced hemodynamic monitoring methods, echocardiographic flow assessment, and perfusion biomarkers including lactate, lactate clearance, and multimarker scores. We review how these parameters are incorporated into the Society for Cardiovascular Angiography and Interventions (SCAI) SHOCK staging and protocols for initiating, titrating, and weaning mechanical circulatory support (Impella, veno-arterial extracorporeal membrane oxygenation), including combined ECPELLA strategies, and we discuss the contemporary randomized trials most relevant to this field, DanGer Shock, ECLS-SHOCK, and ECMO-CS. We also examine how cardiogenic shock etiology and hemodynamic phenotype (e.g., right ventricle-predominant, cardiorenal, cardiometabolic) modify the interpretation and likely generalizability of these parameters. We conclude that integrating flow and perfusion markers with pressure provides a more complete, if not yet fully validated as treatment-guiding, picture of shock severity, while highlighting the continued scarcity of trials that test monitoring strategies themselves rather than the devices they inform.<\/jats:p>","DOI":"10.3390\/jcm15197492","type":"journal-article","created":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T16:50:54Z","timestamp":1790614254000},"page":"7492","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Beyond Blood Pressure: The Role of Flow Parameters and Biomarkers of Hypoperfusion in Cardiogenic Shock"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2928-4225","authenticated-orcid":false,"given":"Shiun Woei","family":"Wong","sequence":"first","affiliation":[{"name":"Department of Cardiology, Tan Tock Seng Hospital, Singapore 308433, Singapore"},{"name":"Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Singapore 308232, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4635-3333","authenticated-orcid":false,"given":"Yew Woon","family":"Chia","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Tan Tock Seng Hospital, Singapore 308433, Singapore"},{"name":"Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Singapore 308232, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1618","DOI":"10.1016\/j.jacc.2025.02.018","article-title":"2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Evaluation and Management of Cardiogenic Shock","volume":"85","author":"Sinha","year":"2025","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"100034","DOI":"10.1016\/j.jacadv.2022.100034","article-title":"Optimal Perfusion Targets in Cardiogenic Shock","volume":"1","author":"Mathew","year":"2022","journal-title":"JACC Adv."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1016\/j.jacc.2022.01.018","article-title":"SCAI SHOCK Stage Classification Expert Consensus Update: A Review and Incorporation of Validation Studies","volume":"79","author":"Naidu","year":"2022","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e024932","DOI":"10.1161\/JAHA.121.024932","article-title":"Association between the Acidemia, Lactic Acidosis, and Shock Severity with Outcomes in Patients with Cardiogenic Shock","volume":"11","author":"Jentzer","year":"2022","journal-title":"J. Am. Heart Assoc."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1186\/s13054-017-1855-2","article-title":"Functional Evaluation of Sublingual Microcirculation Indicates Successful Weaning from VA-ECMO in Cardiogenic Shock","volume":"21","author":"Akin","year":"2017","journal-title":"Crit. Care"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1016\/j.jacc.2022.04.049","article-title":"Criteria for Defining Stages of Cardiogenic Shock Severity","volume":"80","author":"Kapur","year":"2022","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"903","DOI":"10.1016\/j.jchf.2020.08.012","article-title":"Complete Hemodynamic Profiling with Pulmonary Artery Catheters in Cardiogenic Shock Is Associated with Lower In-Hospital Mortality","volume":"8","author":"Garan","year":"2020","journal-title":"JACC Heart Fail."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e021808","DOI":"10.1161\/JAHA.121.021808","article-title":"Invasive Hemodynamic Monitoring in Cardiogenic Shock Is Associated with Lower In-Hospital Mortality","volume":"10","author":"Osman","year":"2021","journal-title":"J. Am. Heart Assoc."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"903","DOI":"10.1016\/j.jchf.2023.04.007","article-title":"Pulmonary Artery Catheter Use and Mortality in the Cardiac Intensive Care Unit","volume":"11","author":"Kadosh","year":"2023","journal-title":"JACC Heart Fail."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1611","DOI":"10.1007\/s12630-021-02083-2","article-title":"Pulmonary Artery Catheterization in Patients with Cardiogenic Shock: A Systematic Review and Meta-Analysis","volume":"68","author":"Chow","year":"2021","journal-title":"Can. J. Anaesth."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"154024","DOI":"10.1016\/j.jcrc.2022.154024","article-title":"Prognostic Implications of Pulmonary Artery Catheter Monitoring in Patients with Cardiogenic Shock: A Systematic Review and Meta-Analysis of Observational Studies","volume":"69","author":"Bertaina","year":"2022","journal-title":"J. Crit. Care"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1016\/j.cardfail.2019.03.004","article-title":"Trends in Utilization and Outcomes of Pulmonary Artery Catheterization in Heart Failure with and without Cardiogenic Shock","volume":"25","author":"Hernandez","year":"2019","journal-title":"J. Card. Fail."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1177\/145749690909800402","article-title":"Complications Associated with Pulmonary Artery Catheters: A Comprehensive Clinical Review","volume":"98","author":"Evans","year":"2009","journal-title":"Scand. J. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1016\/j.jacc.2004.03.060","article-title":"Cardiac Power Is the Strongest Hemodynamic Correlate of Mortality in Cardiogenic Shock: A Report from the SHOCK Trial Registry","volume":"44","author":"Fincke","year":"2004","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"366","DOI":"10.1016\/j.ahj.2006.11.014","article-title":"Cardiac Power Output Predicts Mortality Across a Broad Spectrum of Patients with Acute Cardiac Disease","volume":"153","author":"Mendoza","year":"2007","journal-title":"Am. Heart J."},{"key":"ref_16","first-page":"1173","article-title":"Improved Outcomes Associated with the Use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative","volume":"93","author":"Basir","year":"2019","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1659","DOI":"10.1016\/j.jacc.2018.12.084","article-title":"Standardized Team-Based Care for Cardiogenic Shock","volume":"73","author":"Tehrani","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_18","first-page":"3199","article-title":"Prognostic Value of Right Atrial Pressure-Corrected Cardiac Power Index in Cardiogenic Shock","volume":"9","author":"Baldetti","year":"2022","journal-title":"ESC Heart Fail."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"3674","DOI":"10.1002\/ehf2.14949","article-title":"Cardiac Power Output Ratio: Novel Survival Predictor after Percutaneous Ventricular Assist Device in Cardiogenic Shock","volume":"11","author":"Leung","year":"2024","journal-title":"ESC Heart Fail."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"598","DOI":"10.1177\/03913988221100278","article-title":"Cardiac Power Output Index to Define Hemodynamic Response to Impella Support in Cardiogenic Shock","volume":"45","author":"Lim","year":"2022","journal-title":"Int. J. Artif. Organs"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1061","DOI":"10.1016\/j.cardfail.2021.07.013","article-title":"Right Ventricular Dysfunction Is Common and Identifies Patients at Risk of Dying in Cardiogenic Shock","volume":"27","author":"Jain","year":"2021","journal-title":"J. Card. Fail."},{"key":"ref_22","first-page":"593","article-title":"The Pulmonary Artery Pulsatility Index Identifies Severe Right Ventricular Dysfunction in Acute Inferior Myocardial Infarction","volume":"80","author":"Korabathina","year":"2012","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1002\/ejhf.1679","article-title":"Pulmonary Artery Pulsatility Index: Physiological Basis and Clinical Application","volume":"22","author":"Lim","year":"2020","journal-title":"Eur. J. Heart Fail."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1016\/j.cardfail.2017.10.009","article-title":"Right Ventricular Dysfunction in Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Hemodynamic Analysis of the SHOCK Trial and Registry","volume":"24","author":"Lala","year":"2018","journal-title":"J. Card. Fail."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1016\/j.cardfail.2018.03.008","article-title":"Prognostic Impact of Pulmonary Artery Pulsatility Index (PAPi) in Patients with Advanced Heart Failure: Insights from the ESCAPE Trial","volume":"24","author":"Kochav","year":"2018","journal-title":"J. Card. Fail."},{"key":"ref_26","first-page":"598029","article-title":"Evaluation of Cardiac Function Index as Measured by Transpulmonary Thermodilution as an Indicator of Left Ventricular Ejection Fraction in Cardiogenic Shock","volume":"2014","author":"Perny","year":"2014","journal-title":"Crit. Care Res. Pract."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1007\/s10877-015-9782-8","article-title":"Accuracy and Precision of Transcardiopulmonary Thermodilution in Patients with Cardiogenic Shock","volume":"30","author":"Schmid","year":"2016","journal-title":"J. Clin. Monit. Comput."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2208","DOI":"10.1016\/j.jcin.2020.06.037","article-title":"Arterial Lactate in Cardiogenic Shock: Prognostic Value of Clearance versus Single Values","volume":"13","author":"Fuernau","year":"2020","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_29","first-page":"103996","article-title":"SCAI Door to Lactate Clearance (SCAI DLC) Cardiogenic Shock Initiative: Definition, Hypothesis, and Call to Action","volume":"4","author":"Naidu","year":"2025","journal-title":"J. Soc. Cardiovasc. Angiogr. Interv."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2344","DOI":"10.1093\/eurheartj\/ehab110","article-title":"The Novel Cystatin C, Lactate, Interleukin-6, and N-Terminal Pro-B-Type Natriuretic Peptide (CLIP)-Based Mortality Risk Score in Cardiogenic Shock after Acute Myocardial Infarction","volume":"42","author":"Ceglarek","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1625","DOI":"10.1016\/j.jchf.2024.06.009","article-title":"Continuum of Preshock to Classic Cardiogenic Shock in the Critical Care Cardiology Trials Network Registry","volume":"12","author":"Patel","year":"2024","journal-title":"JACC Heart Fail."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"471","DOI":"10.1002\/ehf2.13097","article-title":"Predicting Parameters for Successful Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock","volume":"8","author":"Sawada","year":"2021","journal-title":"ESC Heart Fail."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1186\/s13054-022-04249-w","article-title":"Parameters Associated with Successful Weaning of Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review","volume":"26","author":"Charbonneau","year":"2022","journal-title":"Crit. Care"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Hsu, H.R., Sekhar, P., Grover, J., Tian, D.H., Downey, C., Maudlin, B., Dissanayake, C., and Dennis, M. (2025). Predictors of Successful Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation (V-A ECMO): A Systematic Review and Meta-Analysis. PLoS ONE, 20.","DOI":"10.1371\/journal.pone.0310289"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"414","DOI":"10.1016\/j.echo.2020.12.002","article-title":"Echocardiographic Predictors of Successful Extracorporeal Membrane Oxygenation Weaning after Refractory Cardiogenic Shock","volume":"34","author":"Kim","year":"2021","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_36","first-page":"358","article-title":"Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) with vs. without Left Ventricular Unloading by Impella: A Systematic Review and Meta-Analysis","volume":"9","author":"Cappannoli","year":"2023","journal-title":"Eur. Heart J. Qual. Care Clin. Outcomes"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Masiero, G., Arturi, F., Panza, A., and Tarantini, G. (2024). Mechanical Circulatory Support with Impella: Principles, Evidence, and Daily Practice. J. Clin. Med., 13.","DOI":"10.3390\/jcm13164586"},{"key":"ref_38","first-page":"100586","article-title":"Mechanical Circulatory Support Devices in Acute Myocardial Infarction-Cardiogenic Shock: Current Studies and Future Directions","volume":"2","author":"Jentzer","year":"2023","journal-title":"J. Soc. Cardiovasc. Angiogr. Interv."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"664","DOI":"10.1016\/j.jchf.2021.05.011","article-title":"A Pragmatic Approach to Weaning Temporary Mechanical Circulatory Support: A State-of-the-Art Review","volume":"9","author":"Randhawa","year":"2021","journal-title":"JACC Heart Fail."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1738","DOI":"10.1007\/s00134-011-2358-2","article-title":"Predictors of Successful Extracorporeal Membrane Oxygenation (ECMO) Weaning after Assistance for Refractory Cardiogenic Shock","volume":"37","author":"Aissaoui","year":"2011","journal-title":"Intensive Care Med."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1286","DOI":"10.1056\/NEJMoa2307227","article-title":"Extracorporeal Life Support in Infarct-Related Cardiogenic Shock","volume":"389","author":"Thiele","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1382","DOI":"10.1056\/NEJMoa2312572","article-title":"Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock","volume":"390","author":"Jensen","year":"2024","journal-title":"N. Engl. J. Med."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"454","DOI":"10.1161\/CIRCULATIONAHA.122.062949","article-title":"Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial","volume":"147","author":"Ostadal","year":"2023","journal-title":"Circulation"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"988","DOI":"10.1002\/ehf2.13180","article-title":"Cardiogenic Shock Teams and Centres: A Contemporary Review of Multidisciplinary Care for Cardiogenic Shock","volume":"8","author":"Moghaddam","year":"2021","journal-title":"ESC Heart Fail."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1184","DOI":"10.1161\/CIRCULATIONAHA.119.043080","article-title":"Value of Hemodynamic Monitoring in Patients with Cardiogenic Shock Undergoing Mechanical Circulatory Support","volume":"141","author":"Saxena","year":"2020","journal-title":"Circulation"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"e020085","DOI":"10.1161\/JAHA.120.020085","article-title":"Phenotyping Cardiogenic Shock","volume":"10","author":"Zweck","year":"2021","journal-title":"J. Am. Heart Assoc."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"e007099","DOI":"10.1161\/CIRCHEARTFAILURE.120.007099","article-title":"Invasive Hemodynamic Assessment and Classification of In-Hospital Mortality Risk Among Patients with Cardiogenic Shock","volume":"13","author":"Thayer","year":"2020","journal-title":"Circ. Heart Fail."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7492\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T17:15:42Z","timestamp":1790615742000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7492"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,26]]},"references-count":47,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["jcm15197492"],"URL":"https:\/\/doi.org\/10.3390\/jcm15197492","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,26]]}}}