Beyond the Pump: Reframing Cardiogenic Shock in Heart Failure Through a Multisystem Mechanistic Lens

Management of patients with cardiogenic shock (CS) has long focused on hemodynamic optimization, yet outcomes remain poor, particularly for those with acute-on-chronic heart failure (ACHF)-CS. This hemodynamic-centric paradigm is largely derived from ST-segment elevation myocardial infarction (STEMI)-CS, which inadequately captures the complex, multisystem physiology of ACHF-CS. The syndrome of ACHF-CS emerges from the simultaneous convergence of central hemodynamic abnormalities in concert with systemic inflammation and microcirculatory dysfunction. This primed convergence of aberrations fuels ongoing organ injury despite hemodynamic recovery-a phenomenon of hemodynamic dissonance. Unlike the acute and abrupt sequential trajectory of STEMI-CS, ACHF-CS is a distinctive mechanistic process shaped by longer-standing central and peripheral maladaptation with systemic stress at onset. This paper distinguishes ACHF-CS as a distinct shock phenotype, and highlights emerging therapeutic strategies aimed at modifying disease biology beyond a focus on solely rescuing hemodynamics. A mechanism-specific approach is essential to improve outcomes in ACHF-CS.