Cardiogenic shock revisited: From hemodynamic-centric to multimodal precision care

Cardiogenic shock (CS) remains a major clinical challenge, with persistently high short-term mortality despite advances in reperfusion therapy, pharmacological support, and mechanical circulatory support. This review reassesses the conceptual evolution of CS and examines why hemodynamic-centric diagnostic and therapeutic strategies have failed to yield meaningful improvements in outcomes. Historically, CS has been defined by cardiac-oriented macrocirculatory compromise, and contemporary definitions and staging systems have improved risk stratification but remain largely hemodynamics-focused and primarily validated in intensive care settings. Increasing evidence indicates that inflammatory activation, microcirculatory dysfunction, endothelial injury, and metabolic derangements are central determinants of shock progression and organ failure. Integrating multimodal diagnostic approaches-including bedside assessment of microcirculation and inflammation, omics-based phenotyping, advanced echocardiographic techniques, and artificial intelligence-assisted risk stratification-may enable earlier recognition, more precise classification, and improved risk stratification across the continuum of care. Reframing cardiogenic shock as a dynamic, multisystem disorder supports a shift from hemodynamic-centric paradigms toward multimodal precision care, with important implications for clinical management and future trial design.