Timing of intervention in cardiogenic shock management: A systematic review and network meta-analysis

Cardiogenic shock (CS) is a critical condition with high mortality rates, necessitating timely interventions to optimize patient outcomes. However, the optimal timing for pharmacological and mechanical interventions remains unclear. This systematic review and network meta-analysis evaluates the impact of intervention timing (early, intermediate, and delayed) on mortality, organ recovery, length of stay in intensive care units (ICUs), and adverse events in CS management. This systematic review and network meta-analysis followed a comprehensive search on PubMed, Embase, Web of Science, and Cochrane Library from inception to 2024 for studies on intervention timing in CS management. Eligible studies involved adult CS patients receiving pharmacological (e.g. inotropes, vasopressors) or mechanical interventions [e.g. extracorporeal membrane oxygenation (ECMO), Impella, intra-aortic balloon pumps]. The extracted data included survival rates, organ recovery, ICU length of stay, and adverse events. A Bayesian network meta-analysis compared early (<2 h), intermediate (2-12 h) and delayed (≥12-24 h) intervention timings, reporting effect sizes as odds ratios, hazard ratios, or mean differences. Heterogeneity was assessed using I² statistics. From 121 records, 14 studies (n = 127,686 patients) were included. Delayed interventions ranked the highest for effectiveness, followed by intermediate and early strategies. Early use of ECMO and pre-percutaneous coronary intervention Impella was associated with reduced mortality and improved organ function in specific settings. However, high uncertainty in the findings suggests cautious interpretation. No significant inconsistencies were found between direct and indirect evidence. Delayed interventions ranked higher in CS management, potentially allowing for better patient stabilization, but high uncertainty necessitates cautious interpretation. Individualized approaches considering patient characteristics and clinical settings are crucial. Further high-quality trials are needed to establish evidence-based timing protocols for CS interventions.